14 Sep 2025 Charlotte Tetley · Prevention of Future Deaths report Cheshire
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Concerns raised 1 Failure to retain patients on the inpatient bed list until appropriate same-day mental health professional review View source
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AI-generated summary
Charlotte Tetley · 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
Charlotte Tetley died after deliberately sitting on railway tracks and being struck by a train on 24 September 2024. The report describes concerns that she was removed from the inpatient bed list before an appropriate mental health review had taken place, despite previous documented reviews stating that inpatient admission was required.
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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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain patients on the inpatient bed list until appropriate same-day mental health professional review
Wider context from the report “That Ms Tetley was removed from the inpatient bed list on the 25 June at 10:37 hours before an attempted review by a mental health practitioner at 11:30 hours the same day . Following daily documented reviews between the 18 June 2024 to the 24 June 2024, it was documented that Ms Tetley required inpatient admission and daily reviews.
I am concerned that there is a risk that patients are removed from the inpatient bed list before an appropriate review that day, by a mental health professional .
” 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 an SOP for escalating clinical differences of opinion about the mental health bed list; the SOP is under peer review.
Verbatim wording from the response “• Learning:
◦ A new Standard Operating Procedure (SOP) – Escalation Process for Clinical Differences of Opinion – Mental Health Bed List – has been developed and is under peer review. This ensures clinical disagreements are escalated to Clinical Directors promptly.
◦ A Patient Flow Meeting now follows the Clinical Prioritisation Meeting to ensure decisions are discussed and communicated across all teams. This meeting focuses on the admissions and discharge planning for all inpatients across CWP.” Source location Response from Cheshire and Wirral Partnership NHS Foundation Trust
Open published response
2 May 2024 Evie Jane DAVIES · Prevention of Future Deaths report Cheshire
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Concerns raised 3 Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors View source Failure to notify the mental health team when a person has contacted the café71 service View source Delays in GP review of correspondence relevant to mental health team action View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Evie Jane DAVIES · 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
Evie Jane Davies was found deceased at home on 2 December 2021 after taking a significant overdose of medication that had not been prescribed to her. The report states that this was likely a deliberate act intended to end her life, amid deteriorating mental health and significant personal stressors. The principal concern was insufficient real-time information sharing between the café71 crisis service, the mental health team and the GP, potentially preventing prompt follow-up of people at risk.
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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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors
Wider context from the report “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team , and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person . They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team . In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner.
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the mental health team when a person has contacted the café71 service
Wider context from the report “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up . It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner.
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in GP review of correspondence relevant to mental health team action
Wider context from the report “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team . I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner.
” 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 Remind crisis line staff to include contact information in referrals and complete warm call transfers where possible.
Verbatim wording from the response “At 20:27 on 1 December 2021 Café 71 staff emailed the crisis line as the referral did not contain a telephone number for Miss Davies. A telephone number was sent from the crisis line via email to Café 71 at 08:35 on 2 December 2021. A reminder has been issued to all” Source location Response from Cheshire and Wirral Partnership
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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 referrals sent to Café 71 every six months and report findings through Acute Care and First Response governance meetings.
Verbatim wording from the response “The following learning has been undertaken by both the Trust and Café 71 to streamline how key information regarding individuals involved with mental health services can be shared with Café 71” Source location Response from Cheshire and Wirral Partnership
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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 Existing procedures require Café 71 to contact relevant mental-health teams, attend professionals’ meetings and notify the Trust after three failed contact attempts.
Verbatim wording from the response “If an individual is known to Community Mental Health Team, Café 71 will link in with the individual’s key workers, this is via email or phone contact. This is set out in the current Community Mental Health Team Standard Operating Procedure. Café 71 staff are also invited to attend professionals’ meetings to provide feedback on the progress of the individual attending Café 71, including the level of engagement with the cafe, when an individual had completed their programme and offer recommendations for future support if appropriate.” Source location Response from Cheshire and Wirral Partnership
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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 Café 71 does not operate in isolation; staff can obtain relevant mental-health information from Trust crisis-line staff with the individual’s consent.
Verbatim wording from the response “Café 71 do not have access to the Trust’s electronic Patient record system (SystmOne). However, the staff from Café 71 will contact crisis line staff to discuss any risk concerns, the teams work closely to ensure that the relevant information relating to a patient’s mental health is available to Café 71 staff. Café 71 staff can phone the crisis line to request further information, but more often the member of staff requiring the information will physically call into the office. Contacts between services are undertaken with patient knowledge and consent. The Trust would seek consent from the individual to refer them to Café 71.” Source location Response from Cheshire and Wirral Partnership
Open published response
30 Sep 2022 Katharine Mary TYRER · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 3 Ward layout failing to support easy observation of vulnerable patients View source Insufficient staffing levels for informal observation, oversight and monitoring View source Lack of a clear protocol for responding to short-term suicide risk after a trigger event View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Katharine Mary TYRER · 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
Katharine Mary TYRER died at the scene on 12 April 2018 after being found unresponsive with a ligature in a bathroom on the Lakefield Ward. The report identified concerns about the ward layout limiting observation, inadequate risk assessment, missed opportunities to respond to increased short-term risk, and the absence of a clear protocol for escalation and enhanced monitoring.
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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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ward layout failing to support easy observation of vulnerable patients
Wider context from the report “1. The ward layout did not lend itself to easy observation of patients. The Court’s expert considered it ‘wholly inadequate’. The jury felt that this contributed more than minimally to Katharine’s death.
A number of rooms (including Katharine’s room, 23) were remote from the nursing station and largely out of sight unless visited for a specific purpose. Whilst I am aware that some changes have been made since 2018, I am concerned that the current layout continues to place vulnerable patients, who might take their own lives, at risk.
It is appreciated that the Trust might not be in a position to create a ward which eliminates all of the layout issues. However, mitigation measures might be appropriate if the present facilities are to be used on an ongoing basis in an unmodified form. I am concerned that the limitations presented by the current layout may mean that staffing levels need to be adjusted to allow for greater levels of informal observation, oversight and monitoring.
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels for informal observation, oversight and monitoring
Wider context from the report “1. The ward layout did not lend itself to easy observation of patients. The Court’s expert considered it ‘wholly inadequate’. The jury felt that this contributed more than minimally to Katharine’s death.
A number of rooms (including Katharine’s room, 23) were remote from the nursing station and largely out of sight unless visited for a specific purpose. Whilst I am aware that some changes have been made since 2018, I am concerned that the current layout continues to place vulnerable patients, who might take their own lives, at risk.
It is appreciated that the Trust might not be in a position to create a ward which eliminates all of the layout issues. However, mitigation measures might be appropriate if the present facilities are to be used on an ongoing basis in an unmodified form. I am concerned that the limitations presented by the current layout may mean that staffing levels need to be adjusted to allow for greater levels of informal observation, oversight and monitoring.
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear protocol for responding to short-term suicide risk after a trigger event
Wider context from the report “2. The argument with her husband was a trigger event for Katharine. She was seen briefly by some ward staff between her return to the ward at around 10:25 and 11:00, but left completely unattended between 11:00-12:00. The jury felt that there was a missed opportunity at this time to affect the outcome and that the assessment of the risk that Katharine posed to herself had been inadequate.
The evidence indicated that ward staff (seemingly regardless of their level of experience and seniority) who attend a patient in a situation like this are left to determine what (if any) action to take based upon their clinical judgement. In particular, it is left to the individual to decide whether escalation to a senior clinician would be appropriate and whether observations or monitoring (or even simply staying with the patient) should be increased for a period of time.
I was told that it would not be unworkable in any scenario such as this (involving knowledge of a trigger event in the case of an impulsive patient with a known history of suicide attempts and self-harm) for there to be a procedure which called for an automatic review by the senior clinician on the ward at the time. However, that is not the current situation. I am concerned that, in the absence of a clear protocol, relatively junior staff (who may not be able to effect an adequate risk assessment) may not be equipped to determine how best to address the short-term risk.
” 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 Reconfigure the ward as a 20-bed facility to improve patient observation and oversight.
Verbatim wording from the response “In response to the above I can confirm that the ward was reconfigured in October 2021 when it has become a 20-bed facility. As a result, the new ward layout assists with observation and oversight. The layout of the ward is in line with the existing estate available. For any new build developments or full refurbishments, the Trust is aware of and would plan the specifications in accordance with the Health Building Note 03-01 (Adult Acute Mental Health Units). This best practice guidance concurs with the Care Quality Commission (CQC) regulatory framework (regulation 15).” Source location Response from Cheshire and Wirral Partnership NHS Foundation 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 Relocate the ligature knife and position nurse stations within ward corridor areas to support appropriate observations.
Verbatim wording from the response “At the time of the incident the ward was a 24-bed facility and was appropriately staffed according to the number of beds. Immediately post incident several improvement actions were taken in respect of the location of the ligature knife and nurse stations situated within the ward (including corridor areas) to support appropriate observations.” Source location Response from Cheshire and Wirral Partnership NHS Foundation 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 Update the Supportive Observation and Engagement Policy to require automatic senior review when non-registered staff identify a trigger event.
Verbatim wording from the response “specific regards to the Supportive Observation & Engagement Policy (CP25) we have further reviewed Issue 12 (Implemented 30 August 2022) and note that in the zonal section of the policy (Appendix 1) it does articulate the need to escalate changes in behaviour to a more senior member of staff in addition to peer independent peer review.” Source location Response from Cheshire and Wirral Partnership NHS Foundation 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 Provide face-to-face clinical risk training using formulation and SystmOne application to all inpatient staff.
Verbatim wording from the response “In addition to the update of the policy, further training is being provided to all in-patient staff as part of a Quality Improvement approach. With effect from December 2022 face to face clinical risk training using a formulation approach will be delivered linking the 5 ’p’s model (predisposition to risk, precipitating factors for risk, perpetuating factors for risk preventative factors for risk) with the practical application of SystmOne (electronic patient record system).” Source location Response from Cheshire and Wirral Partnership NHS Foundation Trust
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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 Staffing is adjusted for the ward environment, patient acuity and individual needs, so further staffing changes are not indicated.
Verbatim wording from the response “The Trust is aware of the limitations of the existing ward environment in respect of the age of the Springview building and the ability to observe all areas and as such the staffing levels are adjusted according to the ward environment, acuity and patient needs.” Source location Response from Cheshire and Wirral Partnership NHS Foundation Trust
Open published response
20 Sep 2021 Uyapo Theodore Hayunga-Macha · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure to provide care and supervision while awaiting assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Uyapo Theodore Hayunga-Macha · 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
Uyapo Theodore Hayunga-Macha went missing from Arrowe Park Hospital on 4 December 2020 before he could be assessed for his mental health. He was found drowned on 9 March 2021, and it remained unclear how he ended up in the water. Concerns were raised about why he was not looked after and why he was left alone while waiting for assessment.
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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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide care and supervision while awaiting assessment
Wider context from the report “On 3 December 2020 Merseyside Police were called to Theo where it was apparent that he was suffering from poor mental health. An ambulance was called and Theo agreed to be taken to Arrowe Park Hospital. It is reported that whilst waiting for Triage that he left without being seen.
Why was he not being looked after? And why was he left alone when waiting for assessment?
” Open source report
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
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Concerns raised 11 Failure of mental health trusts to communicate placement information with private providers and families View source Failure to consider discharge medication and prescribing risk View source Failure of discharge planning to share risk information with GPs and families View source Failure of private providers to obtain relevant clinical information from referring services View source Failure to provide care coordination after placement with a private provider View source Insufficient mental health training and specialist liaison for university welfare staff View source Failure of universities to identify early signs of anxiety and mental health issues in students View source Lack of alternative mental health provision for young adults View source Lack of suitable acute mental health beds for young adults View source Inadequate guidance on glass balustrade safety where climbable furniture is adjacent View source Failure to communicate the change in risk level when patients leave a secure environment View source See 8 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
Hannah Dolly Kaur Bharaj · 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
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health trusts to communicate placement information with private providers and families
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement . A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider discharge medication and prescribing risk
Wider context from the report “2. There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU . As a result Hannah was prescribed a month’s supply of medication;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge planning to share risk information with GPs and families
Wider context from the report “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective . Key information was not shared with the GP or the family particularly when care moved back to the family ;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of private providers to obtain relevant clinical information from referring services
Wider context from the report “5.The expectations around information sharing with private providers and the expectation on private providers contracted by the NHS to seek information. The Priory did not request any notes from the EDU about Hannah . As a result they were unaware of detailed information held by the Trust regarding previously expressed suicidal ideation ;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide care coordination after placement with a private provider
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place ;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and specialist liaison for university welfare staff
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective ;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of universities to identify early signs of anxiety and mental health issues in students
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing . As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage . The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective;
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of alternative mental health provision for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative . The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance on glass balustrade safety where climbable furniture is adjacent
Wider context from the report “8. The guidance in relation to the height of glass balustrades where items such as tables, in cafes open to the public including children and other vulnerable people, are placed in close proximity to the glass. The glass balustrade in John Lewis was at a height that accorded with the required standard but by simply climbing onto the table that was adjacent to the balustrade Hannah was able to easily go over the balustrade.
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the change in risk level when patients leave a secure environment
Wider context from the report “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family;
” Open source report
17 May 2019 Barry Marshall Fullarton · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure to account for how mental disorders manifest over time during mental health assessments View source
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
Barry Marshall Fullarton · 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
Barry Marshall Fullarton died on 17 December 2018 after intentionally falling from the balcony of his bedroom, while suffering from a reactive depressive illness following a stroke. The principal concern was that mental health assessments should account for how a disorder manifests over time, including the possibility that an afternoon assessment during improved mood may not reflect needs during morning low mood.
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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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for how mental disorders manifest over time during mental health assessments
Wider context from the report “Those carrying out mental health assessments should have regard to how a mental disorder manifests in a patient. In this case, the diurnal nature of the reactive depressive illness was evident from the medial records such that an assessor could have documented that the assessment at a particular time when mood was good may not be valid when in low mood .
” 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 Adapt Suicide Prevention Training to include diurnal mood variation when teaching about depression and mental state examination.
Verbatim wording from the response “We produce a Trustwide Learning from Experience report three times a year, in which we plan to summarise this learning as part of that report, confirm the above actions, and follow-up their completion. The next edition, which covers the time period April
July 2019, will be presented at our Trustwide Quality Committee in September 2019. This will ensure oversight of the delivery of the actions we have stated above.
The Suicide Prevention Training will also be adapted to include DMV when teaching around depression and Mental State Examination.” Source location 2019-0159-Response-by-Cheshire-and-Wirral-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 Deliver a Trustwide Grand Round for clinicians to share learning and feedback about diurnal mood variation.
Verbatim wording from the response “We will develop a share learning bulletin to outline the importance of responding to assessments for DMV, and include the consideration as to whether people should and could be seen at different times. This will be circulated to all our clinical teams by the end of July 2019. This will be sent directly to all staff, and will also be included in governance and team meetings.
There will be a Trustwide Grand Round for all clinicians in September 2019, where this learning and feedback will be shared.” Source location 2019-0159-Response-by-Cheshire-and-Wirral-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 Develop and circulate a learning bulletin on recognising diurnal mood variation and considering assessment appointments at different times.
Verbatim wording from the response “It may not always be possible to offer appointments at different times of the day, however, given the concerns you have shared, we plan to use your helpful feedback as learning. As such, the Trust will provide further guidance to our staff regarding ways that they can consider facilitating appointments at different times of the day, through the following actions:” Source location 2019-0159-Response-by-Cheshire-and-Wirral-NHS-Trust
Open published response
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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 Appointments cannot always be offered at different times of day, limiting the ability to respond to diurnal mood variation.
Verbatim wording from the response “It may not always be possible to offer appointments at different times of the day, however, given the concerns you have shared, we plan to use your helpful feedback as learning. As such, the Trust will provide further guidance to our staff regarding ways that they can consider facilitating appointments at different times of the day, through the following actions:” Source location 2019-0159-Response-by-Cheshire-and-Wirral-NHS-Trust
Open published response
15 Dec 2016 Janet Esme Millar · Prevention of Future Deaths report Cheshire
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Concerns raised 1 Training deficit in supporting patients withdrawing from nicotine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Janet Esme Millar · 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
Janet Esme Millar, who had schizophrenia and was detained under section 3 of the Mental Health Act, was admitted to the Rosewood Unit for rehabilitation and later died by suicide, with the medical cause of death recorded as hanging. The report raised concern that some nursing staff may not have been fully engaged in addressing nicotine addiction and that this indicated a possible training deficit alongside the hospital’s non-smoking policy.
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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Training deficit in supporting patients withdrawing from nicotine
Wider context from the report “Most of those admitted to your hospital are addicted to nicotine. Some are suicidal. You have recognised that hand in hand with a non-smoking policy it is necessary to break the cycle of addiction and support those who are withdrawing . It would be a concern if there is a training deficit as identified in the previous section and this would need to be addressed.
” Open source report
30 Jan 2015 Michael Gerard McCrorY · Prevention of Future Deaths report The Wirral
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Concerns raised 2 Failure to record the whereabouts and authorised location of patients on level 1 observations View source Insufficient provision of training, support and professional development for staff to minimise recurrence risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michael Gerard McCrorY · 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 Gerard McCrory died on 16 July 2013 after intentionally driving his car into a tree; he was the sole occupant. The report identifies concerns about inadequate care, treatment, supervision and failure to appreciate and respond to his stated suicide risk. It also raises concerns about recording patients’ whereabouts during level 1 observations and uncertainty about staff training and support.
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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the whereabouts and authorised location of patients on level 1 observations
Wider context from the report “b. In addition clear evidence was heard that though the therapeutic observation policy had been amended the amended policy still required the whereabouts of a patient on level 1 observations to be known but the practice was still to just record that the person was O (off the ward) as opposed to (Out with permission from a specific time going to a specific location) .
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient provision of training, support and professional development for staff to minimise recurrence risk
Wider context from the report “c. The inquest was heard in January 2015 and it was unclear from the evidence as to what training, support and professional development had been given to the staff involved and staff generally with regard to minimising the risk of recurrence of this type of tragic eventuality .
” Open source report
29 Aug 2014 Stephen James Morris · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 3 Failure to exchange sufficient relevant mental health information during cross-area transitions View source Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team View source Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen James Morris · 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
Stephen James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.
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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to exchange sufficient relevant mental health information during cross-area transitions
Wider context from the report “Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:
• I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool.
• By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health.
• When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly .
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team
Wider context from the report “Having concluded this inquest, I now write to you to confirm that in my view you should take action because:
• I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made.
• That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision.
• That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care.
I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns.
” 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 Cheshire and Wirral Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication
Wider context from the report “Having concluded this inquest, I now write to you to confirm that in my view you should take action because:
• I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made.
• That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision.
• That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care.
I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns.
” 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