Counsellor

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First report 8 Nov 2019•Latest report 8 Nov 2019

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
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Cheshire

    AI-generated summary

    Mr Sam 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

    Mr Sam Spooner died at Leighton Hospital on 31 August 2018 after being found unresponsive following an act intended to end his life. The report identified concerns about inadequate multi-agency information sharing, coordination and intervention despite known suicide risk, and excessive reliance on his family to keep him safe.

    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 Counsellor; that does not assign responsibility.

    PFD Monitor interpretation

    Excessive reliance on family members unable to keep a patient safe

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”
    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 Counsellor; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and adequately involve other agencies able to keep a patient safe

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”
    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 Counsellor; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of multi-agency information sharing and communication between health care providers

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”
    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 Counsellor; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adequately intervene after a suicide attempt and further suicide preparations

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”
    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 Counsellor; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adopt an effective multi-agency approach to care during known suicide risk

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”
    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