Concerns raised 3 Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion View source Failure to reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers View source Lack of routine auditing and assurance of expected communication processes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Monitor compliance with communication and transfer processes through local governance, escalating themes and trends for organisational learning and continuous improvement.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Embed adherence to the transfer SOP within ward safety huddles, team handovers, and ward governance processes.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Implement a standard operating procedure defining communication, care, transfer, and return-to-ward responsibilities for patients transferred between mental health and acute services.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Monitor risk-assessment quality through ward management audits and additional Matron-led assurance audits using the AMaT system.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Conduct daily electronic environmental audits, address identified hazards, and escalate matters requiring Estates intervention.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Implement a multidisciplinary, formulation-based safety and risk assessment framework that explicitly considers impulsivity and related risk factors.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Monitor compliance with the mental health–acute hospital memorandum of understanding monthly and reconsider review frequency after six months using performance and escalation data.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Provide training supporting formulation-based risk management, professional curiosity, multidisciplinary collaboration, and information triangulation.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source See 5 more actions
×
AI-generated summary
Natalia Violet Cestaro (known as “Tali”) · 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
Natalia Violet Cestaro, known as “Tali”, was an 18-year-old inpatient who died on 15 November 2023 after ingesting a foreign object, undergoing endoscopic removal, and subsequently developing gastric perforation, sepsis and multi-organ failure. The principal concerns included the proactive assessment of risks from impulsive ingestion, liaison between mental health and acute services, and assurance and auditing of communication processes.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion
Wider context from the report “a) Proactive scope of risk assessment for impulsive ingestion (CWPT)
The evidence raised a concern that risk assessments may focus primarily on specific previously ingested items, rather than undertaking a sufficiently proactive assessment of a wider range of swallowable items within the inpatient environment . Where a patient is known to pose a persistent risk of impulsive ingestion, a predominantly reactive approach risks foreseeable hazards not being identified and mitigated in advance .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers
Wider context from the report “b) Interface working and demonstrable liaison between mental health and acute services (CWPT and UHCW)
The evidence before the inquest disclosed limited detail demonstrating how liaison, shared responsibility, and specialist input are consistently achieved in practice when a mental health inpatient is transferred to an acute hospital for physical healthcare . While both organisations described mechanisms for access to advice and communication, there was relatively limited evidence of how these arrangements operate reliably , how compliance is assured, and how lapses are detected and addressed. This creates a risk that relevant mental health risks are not consistently carried through the acute admission .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of routine auditing and assurance of expected communication processes
Wider context from the report “c) Assurance and auditing of expected communication processes (CWPT)
The evidence raised concern that processes described as standard practice, including regular contact following transfer, may not be subject to routine auditing or assurance . Reliance on the existence of a process alone, without effective oversight of whether it is consistently carried out in practice, risks failures persisting undetected .
” 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 Monitor compliance with communication and transfer processes through local governance, escalating themes and trends for organisational learning and continuous improvement.
Verbatim wording from the response “In addition, compliance with the agreed communication and transfer processes will be monitored through local governance arrangements, providing assurance that expectations are understood, consistently applied and embedded within routine practice. Any themes or trends identified through this monitoring will be escalated through the Trust’s governance structures to support continuous improvement and organisational learning.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed adherence to the transfer SOP within ward safety huddles, team handovers, and ward governance processes.
Verbatim wording from the response “Adherence to the SOP will be embedded within ward safety huddles, team handovers and ward governance processes.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standard operating procedure defining communication, care, transfer, and return-to-ward responsibilities for patients transferred between mental health and acute services.
Verbatim wording from the response “As part of the Safety Improvement Plan accompanying the Patient Safety Incident Investigation (PSII) report, an action was agreed to develop a Standard Operating Procedure (SOP) to provide guidance on communication, care and treatment arrangements for patients open to our services who are conveyed to University Hospital Coventry and Warwickshire (UHCW).” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor risk-assessment quality through ward management audits and additional Matron-led assurance audits using the AMaT system.
Verbatim wording from the response “The quality of risk assessments is routinely monitored through our Audit Management and Tracking (AMaT) system. Audits are undertaken by ward management teams, with additional assurance provided through separate Matron-led audits.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily electronic environmental audits, address identified hazards, and escalate matters requiring Estates intervention.
Verbatim wording from the response “We will continue to undertake daily environmental audits across our mental health wards to identify, address and remove potential and foreseeable hazards. These audits are completed electronically, updated in real time and enable immediate escalation of environmental concerns requiring Estates intervention.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a multidisciplinary, formulation-based safety and risk assessment framework that explicitly considers impulsivity and related risk factors.
Verbatim wording from the response “Our safety (risk) assessment, formulation and planning framework has undergone multidisciplinary review to ensure alignment with National Institute for Health and Care Excellence (NICE) Guideline NG225. The framework incorporates a formulation-based approach that considers factors which may predispose individuals to unsafe behaviours, perpetuate risk, or act as protective influences. Impulsivity is specifically considered within this formulation process.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor compliance with the mental health–acute hospital memorandum of understanding monthly and reconsider review frequency after six months using performance and escalation data.
Verbatim wording from the response “CWPT and UHCW are signatories to a Memorandum of Understanding (MoU) setting out arrangements for patients receiving inpatient mental health care who require physical healthcare treatment within a local acute hospital setting.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide training supporting formulation-based risk management, professional curiosity, multidisciplinary collaboration, and information triangulation.
Verbatim wording from the response “Our training programme supports this formulation-based approach to safety and risk management, with a strong emphasis on professional curiosity, multidisciplinary collaboration and triangulation of information obtained from those important to the individual and those involved in their care. The training encourages staff to consider a broader range of factors that may influence safety and wellbeing and supports a move away from historical documentation and approaches, such as the Skills-based Training on Risk Management (STORM) and Working with Risk (WWR) tools.” Source location Response from Coventry and Warwickshire Partnership NHS Trust
Open published response
16 Jan 2026 Wayne Pierce Walton · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 4 Failure to adequately complete risk assessment and risk formulation documentation View source Lack of guidance for managing conflicts of interest when staff or shadowing persons know a patient outside a personal relationship View source Lack of staff awareness of Home Treatment Team policies and required risk information View source Failure to pass important risk information to the Home Treatment Team View source See 1 more concern
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
Wayne Pierce Walton · 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
Wayne Pierce Walton was discharged from the Caludon Centre on 21 June 2024 after taking an overdose with the intention of ending his life. He failed to engage consistently with the Home Treatment Team and died by asphyxiation on 29 June 2024. Concerns included inadequate completion and transfer of risk assessment and safety plan information, and a lack of guidance on potential conflicts of interest involving staff who recognised a patient outside the circumstances covered by an existing 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately complete risk assessment and risk formulation documentation
Wider context from the report “(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed , the Home Treatment Team were not able to identify a full and up to date risk analysis . Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing conflicts of interest when staff or shadowing persons know a patient outside a personal relationship
Wider context from the report “(2)There is in existence, a policy entitled “Personal Relationships at Work” which addresses personal relationships of a particular type, but which does not address the potential for a conflict of interest when a member of staff, or a person shadowing a member of staff, recognises that they may know a patient other than because of a personal relationship as envisaged in the aforementioned policy . The absence of guidance on how to manage this situation , may place both the member of staff and the patient at risk of harm.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of Home Treatment Team policies and required risk information
Wider context from the report “(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pass important risk information to the Home Treatment Team
Wider context from the report “(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on .
” Open source report
6 Mar 2025 Henok Zaid GEBRSSLASIE · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 2 Ligature risks at the tops of patient bedroom doors in unobserved areas View source Failure to install door-top alarms on patient bedroom doors 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
Henok Zaid GEBRSSLASIE · 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
Henok Zaid GEBRSSLASIE, who was detained under the Mental Health Act at the Caludon Centre, was found partially suspended by a ligature in his bedroom on Sherbourne Ward on 12 August 2021, nearly three hours after his last observation. The report identifies continuing concern about the known high risk posed by bedroom door tops as ligature anchor points and notes that door-top alarms had not been installed on the ward by March 2025.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ligature risks at the tops of patient bedroom doors in unobserved areas
Wider context from the report “ii. It is known (and has been known for some years by the Coventry and Warwickshire Partnership NHS Trust) that the top of a door is a “high risk area” for ligatures in particular patients bedroom which have doors that may be locked by patients from the inside and thereby an unobserved patient area .
iii. The circumstances of this inquest touching upon the death of Henok GEBRSSLASIE in August 2021 accentuated this point.
iv. Such risks carrying with it a clear risk of death .
v. Since the incident it was known that door top alarms is “the way forward” as an environmental change that would mitigate such risk and referred to in a serious investigation report in April 2023, this “way forward” expressed in evidence during the inquest.
vi. There remains (now 42 months post Mr GEBRSSLASIEs death) no door top alarms on the patient bedroom doors at Sherbourne Ward, the Psychiatric Intensive Care Unit, at the Caludon Centre.
vii. The cumulative effect (there ‘seemingly’ no expediency to physically better mitigate this known environmental high-risk issue) is such that a concern as to future deaths exists as of March 2025.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to install door-top alarms on patient bedroom doors
Wider context from the report “ii. It is known (and has been known for some years by the Coventry and Warwickshire Partnership NHS Trust) that the top of a door is a “high risk area” for ligatures in particular patients bedroom which have doors that may be locked by patients from the inside and thereby an unobserved patient area.
iii. The circumstances of this inquest touching upon the death of Henok GEBRSSLASIE in August 2021 accentuated this point.
iv. Such risks carrying with it a clear risk of death.
v. Since the incident it was known that door top alarms is “the way forward” as an environmental change that would mitigate such risk and referred to in a serious investigation report in April 2023, this “way forward” expressed in evidence during the inquest.
vi. There remains (now 42 months post Mr GEBRSSLASIEs death) no door top alarms on the patient bedroom doors at Sherbourne Ward, the Psychiatric Intensive Care Unit, at the Caludon Centre.
vii. The cumulative effect (there ‘seemingly’ no expediency to physically better mitigate this known environmental high-risk issue ) is such that a concern as to future deaths exists as of March 2025.
” Open source report
Concerns raised 4 Reporting system failing to identify substantive patient safety issues View source Reporting system failing to address substantive patient safety issues View source Failure to thoroughly review or clarify Section 17 leave conditions before sign-out View source Lack of accessible and reliable means for service users on unescorted leave to contact the facility View source See 1 more concern
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
Darren Joseph Hope · 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
Darren Joseph Hope died on 3 July 2023 after falling from the 10th-floor building where he lived while on unescorted Section 17 leave. The report identifies concerns about verifying leave conditions, ensuring people on leave can contact the facility, and the ability of the reporting system to identify and address patient-safety issues.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reporting system failing to identify substantive patient safety issues
Wider context from the report “Concern 3: There may be limitations in the reporting system’s ability to identify and address substantive issues that directly impact patient safety. If critical concerns are overlooked, there is a risk that valuable insights for preventing future incidents may be missed, reducing the system's effectiveness in promoting long-term safety improvements.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reporting system failing to address substantive patient safety issues
Wider context from the report “Concern 3: There may be limitations in the reporting system’s ability to identify and address substantive issues that directly impact patient safety . If critical concerns are overlooked, there is a risk that valuable insights for preventing future incidents may be missed, reducing the system's effectiveness in promoting long-term safety improvements.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to thoroughly review or clarify Section 17 leave conditions before sign-out
Wider context from the report “Concern 1: Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave . This lack of verification can lead to unaddressed discrepancies, which may impact the safety and appropriateness of unescorted leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible and reliable means for service users on unescorted leave to contact the facility
Wider context from the report “Concern 2: There may be a lack of accessible or reliable means for service users on unescorted leave to contact the facility if they encounter difficulties . This could impact their ability to seek support or assistance when needed.
” Open source report
Concerns raised 1 Failure to remove an observed item from the home in response to continued suicidal ideation 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
Narjit Gill · 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
Narjit Gill died by hanging on 5 May 2023 after recently receiving mental health support and continuing to express suicidal thoughts. The principal concern was the failure to remove an unspecified item seen during a home visit on 3 May 2023, in light of his continued suicidal ideation.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove an observed item from the home in response to continued suicidal ideation
Wider context from the report “(1) Failure to remove ████████ when it was seen on 3 May 2023 by mental health practitioners who visited Mr Gill at his home, in light of his continued expression of suicidal ideation .
” Open source report
28 Mar 2022 Name not published · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 2 Failure to appoint a care co-ordinator View source Insufficient staffing levels in the North Warwickshire area 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
Name not published · 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
████████ was found hanging at his home address on 25 July 2021, after receiving mental health support for suicidal ideation and awaiting a Care Co-ordinator. The concerns identified were that the failure to appoint a Care Co-ordinator may have contributed to his death and that significant staffing shortages remained in the North Warwickshire area.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a care co-ordinator
Wider context from the report “i. I am concerned that the failure to appoint a Care Co-ordinator may have contributed to████████
████████ death.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels in the North Warwickshire area
Wider context from the report “ii. I am concerned that there remain significant staffing shortages in the North Warwickshire area . I heard evidence that staffing was 65% below recommended levels as of March 2022.
” Open source report
6 Dec 2021 Mr Robert Hammond · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 2 Failure to complete Working with Risk documentation View source Failure to complete initial assessment and care plan documentation 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
Mr Robert Hammond · 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 Robert Hammond was found at his home address on 30 January 2021 after receiving treatment from the Trust from 20 December 2020. During the inquest, it was identified that Working with Risk documentation was not completed on approximately the first nine contacts, and the resulting care plan was described as unsatisfactory.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Working with Risk documentation
Wider context from the report “During the inquest there was evidence that Working with Risk (WWR) documentation was not completed on approximately the first nine contacts with Mr Hammond . The 1st contact was on 23rd December 2020 where 2 hours had been allocated for this task as well as the initial assessment and care plan – none of the written documents were completed. The WWR documents were also not completed (on subsequent contacts) on 31/12/20, 3/01/21, 4/01/21,5/01/21, 6/01/21, 7/01/21, 8/01/21, 10/01/21 and 11/01/21 . The Trust was unable to give an explanation for these failures. As a result, the care plan for Mr Hammond was unsatisfactory.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete initial assessment and care plan documentation
Wider context from the report “During the inquest there was evidence that Working with Risk (WWR) documentation was not completed on approximately the first nine contacts with Mr Hammond. The 1st contact was on 23rd December 2020 where 2 hours had been allocated for this task as well as the initial assessment and care plan – none of the written documents were completed . The WWR documents were also not completed (on subsequent contacts) on 31/12/20, 3/01/21, 4/01/21,5/01/21, 6/01/21, 7/01/21, 8/01/21, 10/01/21 and 11/01/21. The Trust was unable to give an explanation for these failures. As a result, the care plan for Mr Hammond was unsatisfactory.
” Open source report
11 Dec 2020 Ms Katy Ann SAMUELS · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 3 Lack of clear guidance for escorted leave according to patients’ legal status View source Failure to verify escort identity and presence for escorted leave View source Insufficient handover arrangements for escorted leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Katy Ann SAMUELS · 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
Katy Ann Samuels, a detained patient at The Caludon Centre, returned from escorted leave intoxicated after consuming alcohol and cocaine. She was later found with a dressing-gown cord around her neck in her room and died on 25 April 2019 despite resuscitation and hospital treatment. The principal concerns were unclear arrangements for escorted leave, including failure to verify or record the escort and departure time, and insufficient handover and communication procedures.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for escorted leave according to patients’ legal status
Wider context from the report “i. The Coventry and Warwickshire Partnership NHS Trust has a section 17 Leave Policy approved and ratified on the 7th August 2019 with a next review date of the 7th August 2022. The policy is targeted at inpatient and community staff.
Excerpts from the aforementioned policy are:
“Leave is defined as any excursion, which takes the patient outside the hospital grounds for ANY period of time, whether escorted by staff, accompanied by relatives/carers, or unescorted... Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment that involves the patient, carers, and the appropriate community team... The patient should be able to demonstrate to professional carers that he/she is likely to cope outside the hospital... Any conditions, restrictions or limitations applicable during the leave period, along with the destination address for overnight leave, must be clearly documented on the s17 leave form. While it may often be appropriate to authorise leave subject to the condition that a patient is accompanied by a friend or relative (e.g. on a pre-arranged day out from the hospital), responsible clinicians should specify that the patient is to be in the legal custody of a friend or relative only if it is appropriate for that person to be legally responsible for the patient, and if that person understands and accepts the consequent responsibility”
ii. It is paramount that a policy must provide clear unambiguous guidance/ direction to inpatient and community staff particularly in relation escorted leave given the legal status of the patient . A lack of clear direction/ guidance can have serious consequences.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify escort identity and presence for escorted leave
Wider context from the report “iii. The circumstances of this inquest touching upon the death of Katy Samuels accentuated this point. The evidence was that Ms Samuels (a detained patient) can and did leave the hospital grounds without an escort seen to attend the hospital. An escort’s identity is not verified, even if seen, for escorted leave e.g. photo identification. A consequence was no member of staff was aware of precisely what time Ms Samuels left the hospital and if it was in fact with anyone at all. No escort was seen and there is no requirement regarding this. It was on this occasion (20th April 2019) that Ms Samuels returned from leave either alone or with an escort not seen and she was intoxicated from alcohol (toxicological evidence confirmed she had also consumed cocaine). Within hours of her return to the ward she was to be discovered with a ligature around neck.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient handover arrangements for escorted leave
Wider context from the report “iv. An aspect of the evidence was staff handovers are vital and therefore time to enable the same very important. The time set aside for a handover was considered insufficient by some staff. By way of analogy there was no handover to the escort for escorted leave. The evidence was that such a process of ‘handover’ would enable better patient safety, detained patients undoubtedly very vulnerable and at risk of significant harm to themselves.
” 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 Embed revised handover arrangements through staff engagement events and disseminated briefings.
Verbatim wording from the response “To embed our revised arrangements for the management of handover and to ensure that staff are aware of their responsibilities in respect of the Standard Operating Procedure, staff engagement events have been held as well as a series of briefings disseminated. This work will also form part of future local staff induction and preceptorship for new staff. Working with our staff I believe that the revised arrangements will strengthen handover and provide staff with a clear focus and safe handover practice.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
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 Amend and approve the Trust-wide Section 17 Leave Policy, including defined leave categories, revised safety forms, accompanied-leave checks, return-time escalation and shift monitoring.
Verbatim wording from the response “To strengthen and formalise our Section 17 leave arrangements across the Trust's inpatient services, we have consulted with our staff and amended our Section 17 Leave Policy. The changes to this policy include clear definitions of the types of leave:” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
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 and apply a Standard Operating Procedure to standardise clinical handover content and processes across clinical handover situations.
Verbatim wording from the response “A working group was established that consulted with staff in respect of the role and function of the handover process to strengthen and ensure patient safety and wellbeing. The working group have developed a Standard Operating Procedure to both standardise the handover content and the way in which a handover functions and operates. The Standard Operating Procedure applies to all clinical handover situations including:” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review rosters and supporting processes, consult staff-side representatives, and establish a consistent longer protected handover timeframe.
Verbatim wording from the response “The Trust has identified that there is mixed practice across Mental Health providers, with Trusts operating handovers of different duration and taking different approaches. The Trust is using this intelligence to inform its own work in respect of its handover arrangements. The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation to ensure this takes place in accordance with Trust policy.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
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 Adopt SBAR as the communication tool for all identified clinical handover situations.
Verbatim wording from the response “The working group reviewed best practice for handover methodologies and tools across other NHS Trusts and have adopted the ‘Situation, Background, Assessment and Recommendation’ (SBAR) tool, which is a nationally recognised communication tool that facilitates the effective and efficient handover of concise, accurate and relevant information between clinicians and clinical teams. SBAR supports the timely and effective handover of pertinent information which includes, but is not limited to, all” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
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 revised handover responsibilities in future local induction and preceptorship for new staff.
Verbatim wording from the response “To embed our revised arrangements for the management of handover and to ensure that staff are aware of their responsibilities in respect of the Standard Operating Procedure, staff engagement events have been held as well as a series of briefings disseminated. This work will also form part of future local staff induction and preceptorship for new staff. Working with our staff I believe that the revised arrangements will strengthen handover and provide staff with a clear focus and safe handover practice.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
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 identified carers to collect and return patients on Section 17 leave rather than allowing unaccompanied departure to meet them.
Verbatim wording from the response “Following conclusion of the inquest, immediate action was taken to ensure that patients going on leave under the care of family or friends, would be collected from and returned to the ward, by the identified person and not permitted to leave the ward unaccompanied to meet family or friends in the reception area or hospital grounds.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
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 Embed revised Section 17 leave arrangements through staff engagement events and disseminated briefings.
Verbatim wording from the response “To embed our revised arrangements for the management of Section 17 leave and to ensure that staff are aware of their responsibilities in respect of the revised policy, staff engagement events have been held as well as a series of briefings disseminated.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers handovers currently more effective because of work already undertaken, while a consistent timeframe is established after consultation.
Verbatim wording from the response “The Trust will continue to establish a consistent time frame for handover after the required consultation process, however the Trust are confident handovers are currently more effective based on the work already undertaken.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot change handover shift patterns until a robust consultation with unions and staff representatives is completed.
Verbatim wording from the response “The Trust has identified that there is mixed practice across Mental Health providers, with Trusts operating handovers of different duration and taking different approaches. The Trust is using this intelligence to inform its own work in respect of its handover arrangements. The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation to ensure this takes place in accordance with Trust policy.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
17 Jan 2019 Mylon Sheppard · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5 Failure to maintain a system clearly identifying GP and geographical boundaries for local mental health services View source Failure to include willing family members in care planning View source Failure to effectively manage waiting lists View source Failure to maintain a clear Day Hospital process for patient non-attendance View source Failure of effective oversight of duty workers' decisions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mylon Sheppard · 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
Mylon Sheppard hanged himself at home and was found on 3 October 2018. The report identified concerns about oversight of duty workers' decisions, waiting-list management, non-attendance processes, family involvement in care planning, and the identification of GP and geographical boundaries for local mental health services.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a system clearly identifying GP and geographical boundaries for local mental health services
Wider context from the report “(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams ..
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include willing family members in care planning
Wider context from the report “(4) Failure to ensure that family members are included in care planning (where the patient is happy for that to happen) .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively manage waiting lists
Wider context from the report “(2) Failure to effectively manage waiting lists .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a clear Day Hospital process for patient non-attendance
Wider context from the report “(3) Failure to have a clear process at the Day Hospital in respect of non attendance of patients .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of effective oversight of duty workers' decisions
Wider context from the report “(1) Failure of any effective oversight of decisions made by duty workers .
” Open source report
13 Nov 2017 John James Leo Scallan · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 3 Failure to provide adequate and reliable intermittent observations View source Failure to complete observation sheets in line with policy View source Lack of staff knowledge of intermittent observation requirements and observation sheets 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
John James Leo Scallan · 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
John James Leo Scallan was admitted to hospital after sustaining injuries in an alleged assault and was subsequently transferred to a mental health ward as an informal patient. He was found unresponsive following a cardiac arrest, and the levels of sedative drugs in his blood after death exceeded those prescribed. Concerns were raised about the adequacy and reliability of intermittent observations, including staff understanding of the observation policy and reluctance to enter a patient's room to conduct checks.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate and reliable intermittent observations
Wider context from the report “1. 1. The adequacy and reliability of the intermittent observations.
2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation .
The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy.
There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete observation sheets in line with policy
Wider context from the report “1. 1. The adequacy and reliability of the intermittent observations.
2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation.
The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy .
There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of intermittent observation requirements and observation sheets
Wider context from the report “1. 1. The adequacy and reliability of the intermittent observations.
2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation.
The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy.
There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day.
” Open source report
25 Apr 2017 Joleen Linton · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Failure to reliably assess patients' breathing through the door window View source Reluctance by staff to enter patients' rooms to conduct observations View source Lack of clear, directed and succinct observation policy guidance View source Inadequacy and unreliability of hourly observations View source Failure to detect concerns in completed observation charts View source Inaccurate recording of patients' positions in bed on observation charts View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joleen Linton · 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
Joleen Linton died on 3 August 2016 in her room on Spencer Ward, Caludon Centre, after being admitted as an informal patient following an overdose of prescribed drugs. She was discovered deceased at 0800 hours after hourly observations, with concerns about the practicality and reliability of observations, inaccurate recording of her position, reluctance to enter patients’ rooms, and a lack of clarity in the relevant 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably assess patients' breathing through the door window
Wider context from the report “(2) Evidence indicated that in consequence of lighting, distance and obstructions it was not practical to reliably assess, through the door window, whether a patient was breathing ;
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reluctance by staff to enter patients' rooms to conduct observations
Wider context from the report “(5) There was a reluctance by members of staff to enter a patient's room to conduct observations ;
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear, directed and succinct observation policy guidance
Wider context from the report “(6) The extant Trust policy, in relation to observations, lacks the necessary clarity, direction and succinctness that can readily be understood and applied by the members of staff who undertake the observations on the ward .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy and unreliability of hourly observations
Wider context from the report “(1) The practicality, adequacy and reliability of hourly observations ;
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to detect concerns in completed observation charts
Wider context from the report “(4) Potential areas of concern, in relation to the completion of the observation chart, were not detected on the night ;
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients' positions in bed on observation charts
Wider context from the report “(3) The recording of the patient's position in bed was not accurately recorded on the observation chart . At least one entry was, having regard to the evidence, obviously erroneous ;
” Open source report
Concerns raised 1 Failure to ensure onward transfer and continuity of health visiting records after family relocation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bradley David Griffiths · 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
Bradley David Griffiths died on 18 November 2012 after suffering a cardiac arrest at home on 13 November 2012, following two previous Apparent Life-Threatening Events. The cause of the fatal cardiac arrest remained undetermined and the inquest concluded with an open conclusion. A concern was raised that two routine six-week appointments were not kept, and that after Bradley and his mother moved, his location and new GP details were not provided, resulting in his records being sent to “No Trace” storage.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure onward transfer and continuity of health visiting records after family relocation
Wider context from the report “Evidence was heard from ████████ who was Bradley’s Health Visitor. ████████ explained that she only saw Bradley once which was for the first visit on the 30th April 2012. Although two appointments were made with Bradley's Mum for the 6 week routine check to take place, his Mum did not keep them. After the second failed appointment ████████ telephoned Bradley’s Mum on the 26th June 2012 and was informed by her that she had separated from Bradley’s father and she and Bradley were living in the Northampton area with friends and that she had registered with a new G.P. However she would not tell ████████ where she was living or the details of the new GP . As a result ████████ sent Bradley’s records to the "No Trace" storage at the Child Health Department with the expectation they would be sent to the next assigned Health Visitor .
” 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 Incorporate the No Trace and case-supervision arrangements into the Health Visiting Standards document.
Verbatim wording from the response “• Completing a ‘No Trace’ process/checklist, and a follow up review after 3 months;” Source location 2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep the arrangements under review to identify additional improvements that could strengthen the process.
Verbatim wording from the response “The arrangements described above were later incorporated into the Health Visiting Standards document (August 2014). We have kept these arrangements under review, as part of normal process, to ascertain whether any additional improvements can be made to strengthen the process in place.” Source location 2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a No Trace checklist and conduct a follow-up review after three months for children whose records cannot be transferred or traced.
Verbatim wording from the response “At the time of Bradley’s death, our processes for the Transfer Out of case notes and information, did not robustly account for instances where families did not provide a forwarding GP address, or where they preferred incorrect details. Following the incident of Bradley’s death in 2012, the Trust had recognised the concerns that you have raised following the inquest in your PFD report. We can confirm that we had taken steps to develop and then implement robust arrangements for ensuring children’s ‘Transferred Out of Area’ records and arrangements for ensuring appropriate levels of contact with receiving areas, are carefully considered; and in circumstances where staff are unable to locate a child/family. The arrangements that we had already proactively put into place were:” Source location 2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Pre-School Manager supervision of each case before assigning No Trace status, ensuring all avenues to locate the child or family have been considered.
Verbatim wording from the response “At the time of Bradley’s death, our processes for the Transfer Out of case notes and information, did not robustly account for instances where families did not provide a forwarding GP address, or where they preferred incorrect details. Following the incident of Bradley’s death in 2012, the Trust had recognised the concerns that you have raised following the inquest in your PFD report. We can confirm that we had taken steps to develop and then implement robust arrangements for ensuring children’s ‘Transferred Out of Area’ records and arrangements for ensuring appropriate levels of contact with receiving areas, are carefully considered; and in circumstances where staff are unable to locate a child/family. The arrangements that we had already proactively put into place were:” Source location 2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing no-trace checks, supervisory review and Health Visiting Standards are considered sufficient to prevent recurrence.
Verbatim wording from the response “• Completing a ‘No Trace’ process/checklist, and a follow up review after 3 months;” Source location 2015-0090-Response-by-Coventry-and-Warwickshire-NHS-Trust
Open published response
25 Jul 2014 Donna Kirkland · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 4 Lack of staff awareness of the alcohol content and ingestion potential of alcohol based hand sanitising gels View source Patients’ permitted retention of cups and containers of alcohol based hand sanitising gels in their rooms View source Patients’ permitted decanting of alcohol based hand sanitising gels into cups and other containers View source Patients’ unlimited access to alcohol based hand sanitising gels View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Donna Kirkland · 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
Donna Kirkland was found deceased in her bed on 22 August 2013 after ingesting alcohol-based hand sanitising gel while detained on a mental health ward. The principal concerns were patients’ unrestricted access to the gel, permission to decant and keep it in rooms, and insufficient staff awareness of its alcohol content and potential ingestion.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the alcohol content and ingestion potential of alcohol based hand sanitising gels
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested .
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Patients’ permitted retention of cups and containers of alcohol based hand sanitising gels in their rooms
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms ;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Patients’ permitted decanting of alcohol based hand sanitising gels into cups and other containers
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers ;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Patients’ unlimited access to alcohol based hand sanitising gels
Wider context from the report “(1) Patients having unlimited access to alcohol based hand sanitising gels ;
(2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers;
(3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms;
(4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested.
” 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 Review access to and use of alcohol-based hand sanitiser across inpatient units.
Verbatim wording from the response “At the inquest the questions of access to, and use of, alcogel were explored with a number of witnesses from the Trust. Evidence was heard at the inquest, and accepted by the Coroner, that following Donna’s death the Trust had taken steps proactively to review the access to and use of alcogel across inpatient units and to raise the awareness of its staff of the” Source location 2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
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 Replace wall-mounted alcohol-based hand-sanitiser dispensers with alcohol-free alternatives.
Verbatim wording from the response “Alcogel is a key part of infection control measures, both at the Coventry and Warwickshire Partnership NHS Trust and nationwide in both NHS and private hospitals. An alcohol-free alternative has recently become available to NHS and NHS institutions. It does have some drawbacks compared to alcogel. Nevertheless, prior to the hearing of the inquest this summer, the Trust had investigated for itself this alternative, and had decided to replace the wall-mounted alcogel dispensers on its premises with this alcohol-free alternative.” Source location 2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
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 Raise staff awareness of risks associated with ingesting alcohol-based hand sanitiser.
Verbatim wording from the response “At the inquest the questions of access to, and use of, alcogel were explored with a number of witnesses from the Trust. Evidence was heard at the inquest, and accepted by the Coroner, that following Donna’s death the Trust had taken steps proactively to review the access to and use of alcogel across inpatient units and to raise the awareness of its staff of the” Source location 2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
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 Monitor access to and use of alcohol-based hand sanitiser across Trust sites.
Verbatim wording from the response “The Trust will continue to monitor access to and use of alcogel across its sites.” Source location 2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The inquest identified no further steps for the Trust to take to reduce the risk of future deaths.
Verbatim wording from the response “The inquest did not identify any further steps which Coventry and Warwickshire Partnership NHS Trust might take to reduce the risk of future deaths.” Source location 2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Open published response
17 Jun 2014 SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to make direct written Trust-to-Trust referrals when transferring patients to another Trust View source Failure to plan patient transfers to another Trust in advance 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
SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · 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
Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.
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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct written Trust-to-Trust referrals when transferring patients to another Trust
Wider context from the report “I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP , given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust.
” 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 Coventry and Warwickshire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to plan patient transfers to another Trust in advance
Wider context from the report “I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP, given the complex needs and history of Sol and that this should have been planned in advance . Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust.
” 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