Recipient

Cygnet Health Care Limited

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First report 8 Nov 2013•Latest report 27 May 2026

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
7

Naming this recipient

Published responses
43%

Found for named reports

Concerns addressed
13

Across all linked responses

Stated actions
47

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

43%published responses found
47stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Essex

    AI-generated summary

    Abigail Louise SMITH · 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

    Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after unsuccessfully trying to suspend herself, and was pronounced dead at 00:08 on 16 February 2022 from compression of the neck. The report describes concerns about failures in mental-health care, including inaccurate records and diagnosis information, inadequate adjustments for autism and learning difficulties, medication-management problems, and discharge from detention without an effective plan to mitigate a known and immediate risk of suicide.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record changes in mental health diagnosis in discharge summaries

    Wider context from the report

    “1. Abbi spent most of her adult life detained and over 18 months in a specialist Tier 4 mental hospital having been transferred there by her local mental health trust. The Tier 4 specialist team agreed that Abbi did not have a personality disorder. This was a significant change for Abbi and was not accurately set out in the discharge summary. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record medication regimes and changes in medical records

    Wider context from the report

    “5. Medication regimes and changes were not accurately recorded in the medical records, and this included medication that required statutory monitoring and was difficult to decipher even at the inquest. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record changes in mental health diagnosis in Psychology records

    Wider context from the report

    “2. Objectively and subjectively Abbi had appeared to respond positively to Clozapine medication with which she was compliant such that Abbi was discharged back to the care of her local community mental health Trust . The medical records and documentation contained significant cutting and pasting and the change of mental health diagnosis was not contained within the Psychology records. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an individualised care plan

    Wider context from the report

    “3. Expert evidence was there was no individualised care plan recorded for Abbi There were inaccuracies and omissions in her medical records about Abbi’s diagnosis, care and treatment during her care and treatment that were then shared and relied upon by other healthcare professionals in other Trusts. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make adjustments or adaptations to communications and therapy for a patient with autism and learning difficulties

    Wider context from the report

    “4. It was known that Abbi was diagnosed with Autism in her childhood and had learning difficulties. Abbi informed the specialist team that she found group work difficult. No adjustments or adaptions were made to communications with or therapy offered to Abbi. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Illegibility of medical records about medication

    Wider context from the report

    “5. Medication regimes and changes were not accurately recorded in the medical records, and this included medication that required statutory monitoring and was difficult to decipher even at the inquest. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Significant cutting and pasting in medical records and documentation

    Wider context from the report

    “2. Objectively and subjectively Abbi had appeared to respond positively to Clozapine medication with which she was compliant such that Abbi was discharged back to the care of her local community mental health Trust . The medical records and documentation contained significant cutting and pasting and the change of mental health diagnosis was not contained within the Psychology records. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inaccuracies and omissions in medical records about diagnosis, care and treatment

    Wider context from the report

    “3. Expert evidence was there was no individualised care plan recorded for Abbi There were inaccuracies and omissions in her medical records about Abbi’s diagnosis, care and treatment during her care and treatment that were then shared and relied upon by other healthcare professionals in other Trusts. ”
    Open source report

  2. Nottinghamshire

    AI-generated summary

    Peter Dickens · 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

    Peter Dickens died at Bassetlaw District General Hospital on 22 January 2022 after choking on a sandwich while a resident at The Beeches. The report identified persistent non-compliance with Eating and Drinking guidelines, inadequate recording and monitoring of mealtime strategies, and apparent failure to provide the support funded for Peter.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of management and the Multidisciplinary team to effectively monitor compliance with Eating and Drinking Guidance

    Wider context from the report

    “c) The Failure of management and the Multidisciplinary team to effectively monitor compliance with Eating and Drinking Guidance- I have no evidence before me that demonstrates improvement with this important issue ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Persistent staff non-compliance with Eating and Drinking guidelines

    Wider context from the report

    “a) The persistent lack of compliance by staff with Eating and Drinking guidelines- there remains a lack of understanding by Beeches management of the reasons for the lack of compliance- if not understood, it is difficult to rectify in the future ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of recording of specific mealtime strategies required by Eating and Drinking guidelines

    Wider context from the report

    “b) The lack of recording of the specific strategies used at mealtimes when there is an Eating and Drinking guideline in place ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide the funded level of support

    Wider context from the report

    “d) Apparent failure to provide the level of support that was funded for Peter- the costings and support level were set out in his current care and support plan- the Beeches management team appeared unaware that he was funded for a total of 18 hours per day, which is broken down into 12 hours one to one support per day and 6 hours two to one support per 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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Management unawareness of the funded support level and its required staffing allocation

    Wider context from the report

    “d) Apparent failure to provide the level of support that was funded for Peter- the costings and support level were set out in his current care and support plan- the Beeches management team appeared unaware that he was funded for a total of 18 hours per day, which is broken down into 12 hours one to one support per day and 6 hours two to one support per 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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of management understanding of the reasons for non-compliance with Eating and Drinking guidelines

    Wider context from the report

    “a) The persistent lack of compliance by staff with Eating and Drinking guidelines- there remains a lack of understanding by Beeches management of the reasons for the lack of compliance- if not understood, it is difficult to rectify in the future ”
    Open source report

  3. Derby and Derbyshire

    AI-generated summary

    Sobia Tabasim Khan · 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

    Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Uncontrolled overseas travel by recently discharged s.41 restricted patients

    Wider context from the report

    “e. Travel overseas for s.41 restricted patients. ████████ was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk. There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledged that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction, at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also risk. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of police power to arrest people posing a significant risk of death or serious injury

    Wider context from the report

    “c. Police power to arrest where there is a reason to believe a person is at risk of death/serious injury. Whilst I was critical of the failure of the police to take measures that were reasonably available to them to investigate the intelligence that had been received that ████████ was in a relationship, the one power that was not available to them was to arrest him. This leaves a significant gap in the powers that are available to the police to protect individuals who are at risk of death/serious injury. Although I cannot say whether the threshold would have been met in Sobhia’s case, such a power could in future cases ensure that it is understood that where an individual poses a significant risk of causing serious harm in relationships, and there is evidence that he is concealing a relationship, he can be arrested. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide clinicians with full risk-assessment reports for discharge decisions

    Wider context from the report

    “f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary. Given ████████ risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate and misleading risk and progress reports for restricted-patient discharge

    Wider context from the report

    “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny

    Wider context from the report

    “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate recording of risk meetings, decisions and actions

    Wider context from the report

    “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Over-reliance on self-reporting by a manipulative patient about relationships and risk

    Wider context from the report

    “g. Over-reliance on self-reporting. This was a theme that ran throughout the inquest and the various agencies involved. This was a case that required a forensic approach throughout, both in hospital and in the community. It was recognised that ████████ was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship. ████████ risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them. This underlined why his self-reporting could not be relied upon and this something that should have featured in his management throughout, and flagged at the point of discharge. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recall s.41 patients solely posing a significant public risk without mental-health decline

    Wider context from the report

    “d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which ████████ was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that ████████ risk only existed in the context of a decline in his mental health. If an individual subject to a s.41 restriction order poses a significant risk to the public he can be protected if he can be recalled to hospital where further assessment can be undertaken. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of available forensic supervision pathways for s.41 restricted patients

    Wider context from the report

    “b. Ensuring that s.41 restricted patients are supervised under a forensic pathway. In this case no such pathway even existed in the locality. This meant that Mustafa’s supervision was inadequate having regard to the risk that he posed. Such orders are imposed to protect the public from the risk of serious harm. Even where it has been adjudged that any previous offending would not have happened but for a mental disorder, there is still the need for a forensic approach. The risk component must not be overlooked as it was here. Forensic pathways must be available across the country. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate clinical record-keeping of material risk information

    Wider context from the report

    “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to investigate culturally relevant family and community information

    Wider context from the report

    “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete and consider a pre-discharge family assessment

    Wider context from the report

    “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered. ”
    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

    Add the manipulation measurement tool as an HCR-20 addendum and use it for male service users.

    Verbatim wording from the response

    “1. The manipulation measurement tool, currently used for females, to be added as an addendum to the HCR-20 (a Secure Services Standard Risk Assessment tool for baseline risk assessment) and used for males going forward.”

    Source location

    Response from Cygnet
    Page 2 · response
    Published 22 February 2024

    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 and audit section 117 and transfer-of-care meetings to ensure current reports or addenda and detailed minutes are recorded, focusing on specified high-risk discharges.

    Verbatim wording from the response

    “3. Section 117 and transfer of care meetings are monitored and audited at Cygnet Derby to ensure up to date reports or addendums are submitted, and detailed minutes recorded, the main focus being on MoJ, MAPPA, and high profile service user discharges.”

    Source location

    Response from Cygnet
    Page 3 · response
    Published 22 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the potential manipulation measurement tool at CPA and section 117 meetings and complete an audit by 31 May 2024.

    Verbatim wording from the response

    “2. Potential Manipulation and Measurement tool to reviewed at CPAs/s.117 meetings”

    Source location

    Response from Cygnet
    Page 3 · response
    Published 22 February 2024

    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

    Send the full SARA document to the Ministry of Justice with section 17 leave applications and indicate its availability on discharge requests.

    Verbatim wording from the response

    “1. Spousal Assault Risk Assessment (SARA) document are provided in full in professionals CPA meeting/s.117 meeting report packs. There document will be sent as a full document to the Ministry of Justice when applying for section 17 leave permissions from the MOJ. It will be indicated on the Request for Discharge that it is available for the MoJ to view (as the request for discharge form does not allow for attachments).”

    Source location

    Response from Cygnet
    Page 2 · response
    Published 22 February 2024

    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 full SARA documents in professionals’ CPA and section 117 meeting report packs.

    Verbatim wording from the response

    “1. Spousal Assault Risk Assessment (SARA) document are provided in full in professionals CPA meeting/s.117 meeting report packs. There document will be sent as a full document to the Ministry of Justice when applying for section 17 leave permissions from the MOJ. It will be indicated on the Request for Discharge that it is available for the MoJ to view (as the request for discharge form does not allow for attachments).”

    Source location

    Response from Cygnet
    Page 2 · response
    Published 22 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.

    Verbatim wording from the response

    “1. All staff complete a report writing and record keeping developmental Skill workbook as part of their Cygnet induction.”

    Source location

    Response from Cygnet
    Page 3 · response
    Published 22 February 2024

    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 three-monthly audits of record triangulation to ensure information is cross-referenced across record streams.

    Verbatim wording from the response

    “2. Cygnet audits on triangulation of records completed 3 monthly to ensure cross referencing of information in different streams of records.”

    Source location

    Response from Cygnet
    Page 3 · response
    Published 22 February 2024

    Open published response

  4. South Yorkshire (Western)

    AI-generated summary

    Chelsea Blue Louise Mooney · 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

    Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of commissioners to obtain assurance about ligature practice and individual safety

    Wider context from the report

    “9. There were opportunities for commissioners to support Cygnет earlier when case managing Chelsea's package of care. The new behaviour of using ligatures should have invited professional curiosity from Commissioners who should have sought assurance about the overall practice of ligature use and intervention from Cygnет but also what that meant specifically for Chelsea and how Cygnет were keeping her safe. This may have led to a review by Cygnет and a better understanding of Chelsea's ligature use. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate assessment and clarification of capacity-based information-sharing wishes

    Wider context from the report

    “3. The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with Chelsea of understanding the consequences of that decision and neither does it adequately break down the information which Cygnет may wish to share with family. This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her. I would have expected; at Chelsea's age, that a social worker would be involved in supporting her with this decision and reviewing it regularly. This decision about her capacity and information sharing were also not revisited which they ought to have been regularly. Not least because Chelsea's mother was responsible for supporting her with s17 leave and was entitled to fully understand the risks to Chelsea or herself through this. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise and respond appropriately to repeated ligature incidents

    Wider context from the report

    “5. There was limited concern about the number of ligature incidents collectively across the ward. They appear to have been accepted as normal behaviour. There was no record of Chelsea using ligatures prior to her admission onto this ward. This reality for staff appears to have led to a downgrading of the seriousness of the use of ligatures. With staff describing in evidence when they would and would not intervene and what would and would not constitute a serious incident in relation to ligatures (i.e., a hospital admission would be required before it was regarded as a serious incident requiring immediate changes to risk levels and observations). It may be that this approach to ligatures also contributed to the delay in Chelsea's final ligature being removed. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to regularly revisit capacity and information-sharing decisions

    Wider context from the report

    “3. The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with Chelsea of understanding the consequences of that decision and neither does it adequately break down the information which Cygnет may wish to share with family. This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her. I would have expected; at Chelsea's age, that a social worker would be involved in supporting her with this decision and reviewing it regularly. This decision about her capacity and information sharing were also not revisited which they ought to have been regularly. Not least because Chelsea's mother was responsible for supporting her with s17 leave and was entitled to fully understand the risks to Chelsea or herself through this. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to debrief prior ligature and self-harm incidents for future risk planning

    Wider context from the report

    “4. There was no evidence of debrief after prior incidents of ligatures or other self-harm attempts and therefore crucial information about Chelsea's state of mind, motivation and methods was missing from future planning and risk assessments. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to critically explore allegations and trauma-related experiences

    Wider context from the report

    “2. Whilst it is important that the young person is believed and has confidence in those with a therapeutic relationship that she will be believed when she makes disclosures; there was almost no professional curiosity about the allegations and whether they spoke to something else going on with Chelsea. The allegations that were made were blindly accepted by the team and one example where this was problematic is the part of Chelsea's PTSD diagnosis that was based on flashbacks. One of the flashbacks which she described related to finding her aunt dead. Her Aunt was not dead and in fact attended the inquest proceedings however this had not been clarified with the family and the treating team accepted this information from Chelsea unequivocally. It is clear there is a very fine balance to tread as it is clear that Chelsea was suffering from flashbacks and had suffered trauma, there was no demonstrable exploration of this. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adequately assess the impact of ending face-to-face visits on detained young people

    Wider context from the report

    “10. Commissioners also ought to have spoken to Chelsea themselves and assured themselves about the decision not to share information with her family; particularly her mother who had been a huge support for Chelsea prior to Covid-19. The impact of the cessation of face-to-face visits on anyone detained under the mental health act, but particularly young people like Chelsea appears to have been underestimated. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Unpractised and delayed ligature identification and knife response

    Wider context from the report

    “7. The approach of three members of staff checking Chelsea before the ligature knife was brought and used led to avoidable delay. I am aware from the evidence that there are practise exercises involving the 'Red Bag' however I am not clear that the same is practised in relation to the check, identification of a ligature and obtaining and using the ligature knife in these situations. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate review of evolving diagnoses and relevant diagnostic information

    Wider context from the report

    “1. The diagnosis whilst described as not being fixed, was not adequately reviewed. The primary witness for Cygnет in relation to diagnosis lacked professional curiosity even when asked questions in evidence. For example dismissing the potential that Chelsea may be hyperbolic in some of her descriptions of incidents and could that be relevant to diagnosis or treatment; evidence from the family about another member of the family with an autism diagnosis was not followed up (the evidence from Cygnет being that they had not been aware the family wished to explore this); nonetheless in evidence it was dismissed as a possibility. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide clear CPR leadership and task structure

    Wider context from the report

    “8. Whilst in evidence I have heard about the practice exercises using the 'Red Bag' it is clear that there was limited confidence and clarity around the CPR needed for Chelsea. There was not a clear structure of one person leading and others knowing exactly what and how to do tasks. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to equip staff to respond to a crisis when alone with a young person

    Wider context from the report

    “6. Male staff were nervous and uncertain of how to approach Chelsea when they were alone. Clear guidance needed to be made available to them on how to deal with this. Although in evidence staff said that if there was an emergency they would attend even if alone this was not the case in practice as the male member of staff sought female support before recognising that Chelsea was in crisis. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of commissioners to independently assure a family information-sharing decision

    Wider context from the report

    “10. Commissioners also ought to have spoken to Chelsea themselves and assured themselves about the decision not to share information with her family; particularly her mother who had been a huge support for Chelsea prior to Covid-19. The impact of the cessation of face-to-face visits on anyone detained under the mental health act, but particularly young people like Chelsea appears to have been underestimated. ”
    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

    Roll out the clinical skills stations programme across the organisation after piloting it at three sites.

    Verbatim wording from the response

    “73. As per previous aspect. The organisation is piloting clinical skills stations, these will cover three aspects such as observation and engagement, ligature awareness and removal and responding to a deteriorating patient. This will be piloted on three sites and then will be rolled out across the organisation.”

    Source location

    Response from Cygnet Health Care
    Page 18 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide hot and cold incident debriefs, weekly reflective practice and access to hospital-wide cover when staff need breaks or additional support.

    Verbatim wording from the response

    “28. Certain staff members carry radios that are allocated to security, response (which does not include the staff member carrying out the observations), nurse in charge and any staff member on 1:1 or above. All staff members carry an alarm and every ward has a ‘response’ member of staff allocated that can attend to any incident in the hospital. This is again emphasised in training to avoid any future delays. This process allows the staff member who has identified the incident to step back if required and/or carry on with the checks without impacting on a young person’s safety.”

    Source location

    Response from Cygnet Health Care
    Page 8 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate local, regional and group lessons learned through bulletins, governance meetings, incident learning events, clinical networks and conferences.

    Verbatim wording from the response

    “76. The Group Director of Nursing for Cygnet ████████ sends out a Lessons Learnt bulletin with any updates of shared learning. This is accessible on the Cygnet Portal at any time.”

    Source location

    Response from Cygnet Health Care
    Page 18 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Pilot clinical skills stations covering observations, ligature awareness and removal, and response to patient deterioration.

    Verbatim wording from the response

    “36. The organisation is also piloting a programme called clinical skills stations which looks to enhance the training of nurses with practical simulation and these will cover observations and engagement, ligature awareness and removal and responding to a physical deterioration of a patient.”

    Source location

    Response from Cygnet Health Care
    Page 10 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Document consideration of young people’s individual needs, priorities, understanding and associated risks in ward-round summaries.

    Verbatim wording from the response

    “19. The GMC provides guidance on the type of information that patients may need to know before making a decision, and recommends that doctors should do their best to find out about a young person’s individual needs and priorities when providing information about treatment options. It advises that discussions should focus on the young person’s ‘individual situation and risk to them’ and sets out the importance of providing the information about the procedure and associated risks in a balanced way and checking that young person has understood the information given.”

    Source location

    Response from Cygnet Health Care
    Page 6 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use dedicated response staff, radios and alarms so observation staff can maintain checks while other incidents are managed.

    Verbatim wording from the response

    “28. Certain staff members carry radios that are allocated to security, response (which does not include the staff member carrying out the observations), nurse in charge and any staff member on 1:1 or above. All staff members carry an alarm and every ward has a ‘response’ member of staff allocated that can attend to any incident in the hospital. This is again emphasised in training to avoid any future delays. This process allows the staff member who has identified the incident to step back if required and/or carry on with the checks without impacting on a young person’s safety.”

    Source location

    Response from Cygnet Health Care
    Page 8 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Change debrief terminology and policy to post-incident review, and train staff to engage young people after incidents.

    Verbatim wording from the response

    “Changes implemented following Chelsea’s death”

    Source location

    Response from Cygnet Health Care
    Page 7 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement specific communication care plans for every young person, with fortnightly review and documentation of information-sharing decisions and their reconsideration.

    Verbatim wording from the response

    “Changes implemented following Chelsea’s death”

    Source location

    Response from Cygnet Health Care
    Page 5 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete ILS train-the-trainer qualification for the resuscitation lead.

    Verbatim wording from the response

    “71. The resuscitation lead has also been nominated to complete the ILS train the trainer course which allows her to then teach the ILS course. This is currently completed by an external trainer.”

    Source location

    Response from Cygnet Health Care
    Page 17 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide nurse drop-in sessions with the ILS lead, including practical refresher training on emergency equipment.

    Verbatim wording from the response

    “71. The resuscitation lead has also been nominated to complete the ILS train the trainer course which allows her to then teach the ILS course. This is currently completed by an external trainer.”

    Source location

    Response from Cygnet Health Care
    Page 17 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide monthly unannounced resuscitation drills, assess response times, record responders and retrain staff where issues are identified.

    Verbatim wording from the response

    “70. In addition the Hospital has a schedule of resuscitation drills that are carried out monthly at an unannounced time and part of the drill includes staff response times. The resuscitation drills are completed by the Resuscitation Lead for Cygnet Hospital Sheffield and the local Quality Manager. The resuscitation drills are assessed and a compliance percentage is generated. The Staff members’ names that respond are also logged. If there is an identified issue raised regarding a specific staff member or any practice then they are put on the next BLS or ILS course as a refresher. The resuscitation lead is also a BLS trainer which allows for quick turnaround of training and also allows for in depth discussion and analysis following the drills.”

    Source location

    Response from Cygnet Health Care
    Page 17 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement flexible post-incident review approaches, including informal reviews or reviews conducted by a person selected by the young person, and communicate them to staff.

    Verbatim wording from the response

    “27. Different approaches have now been agreed by the young people in the community meetings with regards the completion of post incident reviews. The”

    Source location

    Response from Cygnet Health Care
    Page 7 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement and maintain daily oversight and monthly review of incident themes and trends to identify and reduce ward risks.

    Verbatim wording from the response

    “33. All incidents are reported using the Incident Management System (IMS). There is daily ward level and Senior Management oversight on the number, type and severity of incidents on each ward every day, collectively and for each young person. This is to ensure that the senior management team are aware of the risk that is present and also respond if there is a need to add further support mechanisms onto any ward. This could be for example, to stop admissions, to add extra staff, to arrange an activity coordinator and so on. It also allows the senior management to be able to apply quality control measures daily and ensure all reporting to external agencies are completed in a timely manner. This process also allows the senior management team to be able to identify themes and trends.”

    Source location

    Response from Cygnet Health Care
    Page 9 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS England is responsible for commissioning and assuring the quality of the service, including management of risk and ward culture.

    Verbatim wording from the response

    “40. NHS England are responsible for the commissioning and quality of the service they are commissioning. The management of risk and ward culture are central to their quality assurance.”

    Source location

    Response from Cygnet Health Care
    Page 10 · response
    Published 3 October 2022

    Open published response

  5. Exeter and Greater Devon

    AI-generated summary

    Lewis Charles Francis · 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

    Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum

    Wider context from the report

    “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment

    Wider context from the report

    “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies. ”
    Open source report

  6. Inner West London

    AI-generated summary

    Lisa Marie Inkin · 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

    Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record calls taken from patients by the ward

    Wider context from the report

    “7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to 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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing to answer patients’ phone calls

    Wider context from the report

    “7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to 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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to promptly escalate information about patients’ suicidal intent

    Wider context from the report

    “6. The failure on the part of the ward staff at Cygnet to appropriately escalate the information that they received about suicidal intent on Lisa’s part until the day after the information was received and it was too late for any preventative action to be taken. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training or experience to recognise the importance of information about patients’ suicidal intention

    Wider context from the report

    “8. Possible lack of training or experience on the part of Cygnet ward staff to understand the importance of receiving information about suicidal intention of one of their 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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of overnight supervision for patients being treated for eating disorders

    Wider context from the report

    “4. The lack of overnight supervision of patients being treated for eating disorders in Kent. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Transport difficulties disrupting access to eating disorder therapy

    Wider context from the report

    “5. The possibility of transport difficulties with potential problems on pick up such as refusal to leave the home address, not being ready at the appointed time etcetera, spending more time in transport than in therapy. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of local inpatient specialist eating disorder beds

    Wider context from the report

    “2. The complete lack of any local in-patient specialist eating disorder beds. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Shortage of local general adult psychiatric inpatient beds

    Wider context from the report

    “1. The shortage of local General Adult Psychiatric in-patient beds. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training or experience on when and how to escalate information about patients’ suicidal intent

    Wider context from the report

    “9. Possible lack of training or experience on the part of ward staff at Cygnet as to when and how to escalate information about suicidal intent expressed by a patient. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failures in communication between local services and out-of-area psychiatric care providers

    Wider context from the report

    “3. The communication between local services and out of area providers of psychiatric care. ”
    Open source report

  7. West Yorkshire (West)

    AI-generated summary

    Peter Patrick Adrian Barnes · 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

    Peter Patrick Adrian Barnes died from asphyxia caused by hanging in the grounds of Cygnet Hospital, Wyke, while detained under Section 3 of the Mental Health Act 1983. Serious incidents known to nursing staff, including comments about suicide and marks on his neck, were not communicated to the Responsible Clinician, who granted unescorted leave. The report raised concerns about systems for communicating and auditing information and care decisions, involving families in care decisions, and sharing information with police when patients were absent without leave.

    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication of nursing staff information to Responsible Clinicians

    Wider context from the report

    “(1) The hospital’s systems by which information about patients relating to matters which had been observed by nursing staff - including in particular information about serious incidents - were communicated to the patients’ Responsible Clinician appeared to be inadequate to ensure that such information was full and/or accurate and/or up to date. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a system inviting patients’ families to participate in care decisions

    Wider context from the report

    “(4) There appeared to be no system to ensure that members of patients’ families were invited to be involved in the process by which decisions are made about their care, notwithstanding that they may often be able to impart useful information based upon the patient’s past behaviour, potentially including information about particular matters which might increase or decrease the risk of harm to or self-harm by such 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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate access by staff reporting absent patients to information required by police

    Wider context from the report

    “(5) The hospital’s procedure for responding to patients being absent without leave included reporting such patients to the police as missing persons, but did not appear to be adequate to ensure that members of staff so reporting, or thereafter giving further information, to the police had access to all of the information about the patient which was likely to be required by the police for the purpose of their enquiries. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate Responsible Clinician care decisions to nursing staff appropriately and promptly

    Wider context from the report

    “(2) The hospital’s systems by which decisions about patients’ care made by the Responsible Clinician were communicated to nursing staff appeared not to have operated properly and accordingly may be inadequate to ensure that such information about such decisions is communicated in an appropriate and/or timely manner. ”
    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 Cygnet Health Care Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of checking and auditing of clinical information communication systems

    Wider context from the report

    “(3) There appeared to be no system of checking upon or auditing the systems referred to at paragraphs (1) and (2) above to ensure that the Responsible Clinician was receiving full, accurate and up to date information and that nursing staff were receiving appropriate and timely information about the Responsible Clinician’s decisions. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

43%
43%All other recipients 58%
0%100%

How actions were described at the time

This respondent
57%13%30%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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