9 Dec 2025 Hannah Louise Booth · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Failure to record or cross-reference information relevant to both mother and baby in both records View source Lack of a single electronic patient record accessible to all services View source Lack of shared policies, guidance and understanding about information relevant for sharing between services View source Failure to escalate and share increasing contact with health visitors with perinatal mental health services 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.
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AI-generated summary
Hannah Louise Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.
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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record or cross-reference information relevant to both mother and baby in both records
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a single electronic patient record accessible to all services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared policies, guidance and understanding about information relevant for sharing between services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and share increasing contact with health visitors with perinatal mental health services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report
20 May 2024 Miriam STONE · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Lack of a formal policy protecting staff handover time from admissions View source Failure to clearly allocate responsibility for admission tasks during staff handover View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Miriam STONE · 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
Miriam Stone died on 20 February 2022 after being found with a ligature around her neck in a mental health unit on 18 February, following admission after an overdose. The concerns included uncertainty over responsibility for admission tasks during staff handover, a lack of formal policy protecting handover time, inadequate or incomplete risk and safety assessments, and observations that were not individually assessed and were found likely inappropriate.
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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal policy protecting staff handover time from admissions
Wider context from the report “Miriam was admitted to the mental health unit at approximately 8.30pm. The unit has a staff handover between 9.00pm and 9.30pm. The evidence at inquest was contradictory as to which shift had assumed responsibility for completing admission tasks including risk assessments and care / safety plans. It was recognised that admission shortly before or during shift handover can increase risks relating to the quality of information sharing and the allocation of admission tasks such as assessing the level of observations required.
The court heard evidence that whilst efforts would be made to avoid admission during staff handover time this was a local practice rather than part of any formal policy . The court further heard evidence that senior staff considered that avoidance of admission at handover times would be difficult to achieve because there were too many different organisations who might be requesting admission. This appeared to overlook the fact that it is the bed allocation team based at the trust who are the central point of contact.
The current operational policy covering admission procedures (Acute Inpatient Operational Policy) does not mention a need for handover time to be protected, avoiding admission during this time. Without a formal policy on this topic there is a risk that future deaths could occur.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly allocate responsibility for admission tasks during staff handover
Wider context from the report “Miriam was admitted to the mental health unit at approximately 8.30pm. The unit has a staff handover between 9.00pm and 9.30pm. The evidence at inquest was contradictory as to which shift had assumed responsibility for completing admission tasks including risk assessments and care / safety plans. It was recognised that admission shortly before or during shift handover can increase risks relating to the quality of information sharing and the allocation of admission tasks such as assessing the level of observations required .
The court heard evidence that whilst efforts would be made to avoid admission during staff handover time this was a local practice rather than part of any formal policy. The court further heard evidence that senior staff considered that avoidance of admission at handover times would be difficult to achieve because there were too many different organisations who might be requesting admission. This appeared to overlook the fact that it is the bed allocation team based at the trust who are the central point of contact.
The current operational policy covering admission procedures (Acute Inpatient Operational Policy) does not mention a need for handover time to be protected, avoiding admission during this time. Without a formal policy on this topic there is a risk that future deaths could occur.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formalise in policy the avoidance of acute-ward admissions during staff handover unless urgently required for immediate patient safety.
Verbatim wording from the response “I am informed that the Trust confirmed to court on 7 May 2024, following an update from the manager of the bed management team that it was already the custom and practice of the bed management team to not, wherever possible, admit patients during handover times and that this custom and practice was already in operation at the time of the inquest but was due to be placed into the revised policy which had recently been under review. The Trust however acknowledged that due to the presenting risk of a patient it may not always be possible to avoid handover times given the urgent nature of the services the Trust provides.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the amended acute-admission policy to the bed management team.
Verbatim wording from the response “On Wednesday, 8 May 2024 the Trust sent to your office confirmation that the policy which governs the admission to an acute ward, ‘Acute Inpatient Mental Health Services for Adults of Working Age Policy and Procedure’, had been amended to include the line detailed below. That correspondence also confirmed that the updated version had been communicated to the bed management team already but would be formally approved on 6 June 2024.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing practice and policy formalisation were considered sufficient to mitigate the risk of admissions during staff handover periods.
Verbatim wording from the response “I am informed that the Trust confirmed to court on 7 May 2024, following an update from the manager of the bed management team that it was already the custom and practice of the bed management team to not, wherever possible, admit patients during handover times and that this custom and practice was already in operation at the time of the inquest but was due to be placed into the revised policy which had recently been under review. The Trust however acknowledged that due to the presenting risk of a patient it may not always be possible to avoid handover times given the urgent nature of the services the Trust provides.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
16 Feb 2024 Sobia Tabasim Khan · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 12 Uncontrolled overseas travel by recently discharged s.41 restricted patients View source Absence of police power to arrest people posing a significant risk of death or serious injury View source Failure to provide clinicians with full risk-assessment reports for discharge decisions View source Inadequate and misleading risk and progress reports for restricted-patient discharge View source Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny View source Inadequate recording of risk meetings, decisions and actions View source Over-reliance on self-reporting by a manipulative patient about relationships and risk View source Failure to recall s.41 patients solely posing a significant public risk without mental-health decline View source Lack of available forensic supervision pathways for s.41 restricted patients View source Inadequate clinical record-keeping of material risk information View source Failure to investigate culturally relevant family and community information View source Failure to complete and consider a pre-discharge family assessment View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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 Derbyshire Healthcare NHS Foundation Trust; 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train Forensic Community Mental Health Team clinicians in report writing to required forensic standards.
Verbatim wording from the response “The Trust is conscious that clinical teams, the Ministry of Justice and the MHRT rely on the information that is provided to them to consider risk and understand their own role in a patient’s care. To that end the Trust’s FCMHT has been provided with training on report writing to ensure that the information contained within the reports that it writes (to other clinicians, to MHRT and to the MoJ) are of the standards associated with a FCMHT.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide forensic clinical supervision and review for restricted patients who are not managed by the Forensic Community Mental Health Team.
Verbatim wording from the response “The Trust still has a small number of patients subject to s. 41 restrictions who are not under the care of the FCMHT. This approach is based on clinical need and the progress to recovery each patient has made; balancing the potential benefit of being supported by a FCMHT against the potential for a new clinical team in destabilising their recovery. Where clinicians do hold a restricted s. 41 patient on their caseload, they are mandated to receive forensic clinical supervision from the FCMHT. More broadly the FCMHT reviews any s. 41 restricted patient who are not under the care of the FCMHT to ensure they are receiving the appropriate level of care, support and supervision as would be expected of a patient subject to restrictions.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess new Forensic Community Mental Health Team patients through two-staff assessment, multidisciplinary discussion and structured risk and diagnostic tools.
Verbatim wording from the response “The initial assessment of a patient before they are accepted into the FCMHT will be conducted by two staff members followed by a full MDT discussion – the purpose of this approach is to reduce the possibility of having a subjective view of a patient’s need and risks. The FCMHT are trained in conducting structured risk assessments to assess the level of risk posed and structured diagnostic assessments to support diagnosis. These tools are used to augment subjective clinical decision making with objective measures of assessment. Examples of the tools used: the Psychopathy Checklist and International Personality Disorder Examination Assessment.” Source location Response from Derbyshire Healthcare NHS Foundation 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 Audit records of patients subject to sections 37/41 and reinforce record-keeping standards through staff supervision.
Verbatim wording from the response “The Trust conducts ongoing record keeping audits of the medical records of all patients who are subject to a s.37/41 to ensure that they meet the standards required. This audit process is reinforced by a robust supervision process for all nurses / AHPs working with those patients.” Source location Response from Derbyshire Healthcare NHS Foundation 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 Maintain a full Forensic Community Mental Health Team providing multidisciplinary care for Derbyshire patients.
Verbatim wording from the response “With the support of commissioners, the Trust has invested into a Forensic Community Mental Health Team (“FCMHT”) over a 4-year period. The sum invested is £2.7 million. The monies provided have created a full multi-disciplinary team which provides care to the patients of Derbyshire. The approach taken by the FCMHT is guided by evidence from the Royal College of Psychiatrists and NHS England. The Trust is mindful of the complex nature of those patients who are under the care of the FCMHT and as such seeks only to recruit experienced clinicians.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Matters requiring legislative changes are outside the Trust’s control, so it focuses only on issues within its organisational control.
Verbatim wording from the response “The Trust notes that the Prevention of Future Death Report is wide ranging and encompasses different areas, some of which are out of the control of the Trust as they would require legislative changes. In answering below, the Trust has focused on those matters that are under its control as an organisation.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some restricted patients remain outside the forensic team where transfer could destabilise recovery, with existing clinical review and supervision continuing.
Verbatim wording from the response “The Trust still has a small number of patients subject to s. 41 restrictions who are not under the care of the FCMHT. This approach is based on clinical need and the progress to recovery each patient has made; balancing the potential benefit of being supported by a FCMHT against the potential for a new clinical team in destabilising their recovery. Where clinicians do hold a restricted s. 41 patient on their caseload, they are mandated to receive forensic clinical supervision from the FCMHT. More broadly the FCMHT reviews any s. 41 restricted patient who are not under the care of the FCMHT to ensure they are receiving the appropriate level of care, support and supervision as would be expected of a patient subject to restrictions.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
7 Nov 2023 Terri Liz Harris and 3 others · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 10 Insufficient or absent probation domestic abuse and child safeguarding checks View source Insufficient or untimely domestic abuse and child safeguarding training for probation practitioners View source Failure to ensure that PSR reports accurately evidence completed checks View source Failure to report potentially risk-indicating offender comments from electronic monitoring View source Failure to maintain accurate, prominent and readily updateable offender risk records View source Failure to complete domestic abuse and child safeguarding checks before proposing curfew conditions View source Uncertainty about contacting homeowners or lead tenants to assess curfew-address suitability View source Failure to promptly notify the Probation Service of missed substance misuse appointments View source Failure to review offender records at critical risk-assessment points View source Failure to conduct child safeguarding checks where offenders will live with or access children View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terri Liz Harris and 3 others · 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
Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.
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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient or absent probation domestic abuse and child safeguarding checks
Wider context from the report “The inquests identified that DA and SG checks were either insufficient or wholly lacking at various stages of Damien Bendall’s offender management. The current evidence is that DA and SG checks remain generally insufficient or are not being done with consequent on-going risks to children and women.
Insufficient or absent PS DA and SG checks has been a theme of HM Inspectorate of Probation reports and reviews for at least the last 5 years. On HM Inspectorate of Probation case sampling to determine whether domestic abuse and child safeguarding enquiries were being undertaken when indicated, the HM Inspectorate of Probation Annual Report for 2022/2023 states at page 38:-
where inspectors judged that these enquiries needed to be made by the probation practitioner, child safeguarding enquiries were carried out in 55 per cent of cases, domestic abuse enquiries were only carried out in 49 per cent of cases and risk of harm was only properly addressed in 39 per cent .
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient or untimely domestic abuse and child safeguarding training for probation practitioners
Wider context from the report “A significant issue in the inquests was the fact that the very inexperienced staff who were (wrongly) allocated Damien Bendall’s case on transfer to the East Midlands PS region had insufficient DA and SG training. The PS states it has introduced more robust DA and SG training, but it is unclear whether PS practitioners are receiving this before cases are allocated to them to manage .
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that PSR reports accurately evidence completed checks
Wider context from the report “There is no evidence that DA and SG checks were made by the PS practitioner in respect of Damien Bendall’s PSR report. Via the report the court was informed that checks had been conducted. The PS practitioner put forward a curfew provision as appropriate and the report was written in such a way to indicate that the report writer had checked the suitability of the curfew address, when she had not in fact done so . Had the court not been misled it is unlikely that the court’s disposal would have included a curfew requirement.
The inquests heard that PSRs written by the same PS practitioner, reviewed before her submission of Damien Bendall’s PSR, and reports reviewed after the murders, also lacked evidence of DA and SG checks having been made even though they were stated to have been done in the reports .
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report potentially risk-indicating offender comments from electronic monitoring
Wider context from the report “Damien Bendall made the comment “If this relationship goes bad I’ll murder my girlfriend and the children” to the EMS field operative who fitted his tag and monitoring equipment but this was not reported back by the field operative to her manager nor to the PS. EMS has stated that it has introduced relevant training but the inquest heard evidence from the field operative that comments made by offenders which can be interpreted as potentially posing risk are currently routinely not being reported back by EMS field operatives .
The inquests examined the relevant contract terms between the Ministry of Justice and Capita (EMS) relating to reporting concerns and there did appear to be lack of clarity on reporting mechanisms and issues to report .
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate, prominent and readily updateable offender risk records
Wider context from the report “The inquests identified that very concerning information regarding Damien Bendall was made known to the PS (including violent assault and injury of a partner, and an incident of possible child sexual abuse) but was not recorded clearly or prominently for subsequent PS practitioners to read and evaluate in risk assessment and decision-making , and indeed was not read at key and critical points. Although this was in part due to the recording made by individual PS practitioners it was also the result of confusing proformas (e.g. the OASys misleading drop-down boxes and the open and closed sections), imprecise arrangements and expectations of how and where such information should be recorded, and where checks should be directed to and made when the records needed to be reviewed. The inquests were informed of current PS expectations for recording offender risk information and assessments, but I remain very unsure that there are clear and efficient recording arrangements and systems to ensure that risk information is accurate, prominent, easily seen, and easily updateable by PS practitioners .
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete domestic abuse and child safeguarding checks before proposing curfew conditions
Wider context from the report “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children.
The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about contacting homeowners or lead tenants to assess curfew-address suitability
Wider context from the report “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children.
The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly notify the Probation Service of missed substance misuse appointments
Wider context from the report “The precise number is not clear on the records, but he missed 4 or 5 appointments with the service between 21 July and his first attended appointment on 17 September 2021, but the required proforma attendance/non-attendance forms were not sent by the substance misuse service to notify the PS .
Such non-attendance is non-compliance with the court-imposed alcohol treatment requirement and should be considered by the PS practitioner for referral back to the court as a breach of the court order. Clearly it is vital that non-attendance is formally and quickly notified to the PS practitioner especially where there is a relationship between use of substances and violent offending.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review offender records at critical risk-assessment points
Wider context from the report “The inquests identified that very concerning information regarding Damien Bendall was made known to the PS (including violent assault and injury of a partner, and an incident of possible child sexual abuse) but was not recorded clearly or prominently for subsequent PS practitioners to read and evaluate in risk assessment and decision-making, and indeed was not read at key and critical points . Although this was in part due to the recording made by individual PS practitioners it was also the result of confusing proformas (e.g. the OASys misleading drop-down boxes and the open and closed sections), imprecise arrangements and expectations of how and where such information should be recorded, and where checks should be directed to and made when the records needed to be reviewed . The inquests were informed of current PS expectations for recording offender risk information and assessments, but I remain very unsure that there are clear and efficient recording arrangements and systems to ensure that risk information is accurate, prominent, easily seen, and easily updateable by PS practitioners.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct child safeguarding checks where offenders will live with or access children
Wider context from the report “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children.
The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases.
” 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 Implement agreed probation feedback-form notifications after attended and missed Phoenix Futures appointments.
Verbatim wording from the response “Following these discussions, it has been agreed that any attendance by an individual open to probation will via the Probation Feedback Form within 48 hours of attended appointments and 24 hours of a failed appointment; a failed appointment being when an individual does not attend the planned appointment for whatever reason. For failed appointments the Feedback Form will include the efforts made to establish contact with the individual.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
Open published response
16 Oct 2015 Louise Sharon Henry · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Lack of GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information View source Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities View source Failure of discharge letters to identify mental health relapse risks and indicators View source Failure to distinguish Recovery Team services operated by different agencies View source Failure to follow required patient discharge processes and procedures View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Sharon Henry · 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
Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information
Wider context from the report “4. That GPs do not appreciate the use that can be made of the Special Patient Note facility and Right Care plan facility on the EMIS system operated by GPs. I heard evidence that key information relating to patients and in particular mental health patients can be updated on to the Special Patient Note facility and the Right Care Plan facility by GPs and used to record risk relapse triggers and indicators for patient’s with mental health difficulties and risk of suicide/ self harm. This enables Out of Hours Services such as those operated by Derbyshire HealthCare United to access key risk information when they are called out of hours when the GP and the full GP records with this key information is not available. There appears to be action that can be taken by NHS England through the Clinical Commissioning Groups to educate GPs as to this facility.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
Wider context from the report “1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge letters to identify mental health relapse risks and indicators
Wider context from the report “2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required . My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occurring.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish Recovery Team services operated by different agencies
Wider context from the report “3. There is a misunderstanding in respect of the Recovery Team from DCC and the Recovery Team within the CMHT and potential for confusion between professionals and service users due to there being 2 services operating under the title “Recovery Team” operated by different agencies namely DCC and the CMHT.
” 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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow required patient discharge processes and procedures
Wider context from the report “2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required. My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occurring.
” 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 Circulate a DCHFT staff briefing to raise awareness of discharge-related risks and requirements.
Verbatim wording from the response “7. A staff briefing has been circulated raising awareness relating to this issue across DCHFT.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-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 the Self-Directed Support framework into social work practice so discharges are structured and robust.
Verbatim wording from the response “1. The Council is clear that the discharge arrangements set out in its Self-Directed Support (“SDS”) policy must be properly applied in every case. This is the policy relevant to social workers, NOT the Care Programme Approach (“CPA”) although they are intended to be complementary. Adherence to this policy ensures that following the decision to discharge someone from social care support they are properly informed as to the reasons for this decision and any alternative sources of support.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-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 Raise the discharge-communication issue at the Trust Medical Advisory Committee to increase awareness among DCHFT psychiatrists.
Verbatim wording from the response “9. The issue will be raised at the Trust Medical Advisory Committee to raise awareness with all DCHFT psychiatrists.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-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 benchmarking and follow-up audits of discharge letters.
Verbatim wording from the response “10. A benchmarking audit and follow up audit of discharge letters is to be conducted by ████████” Source location 2015-0013-Response-by-Derbyshire-Healthcare-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 Email fieldwork staff a reminder of Self-Directed Support processes, particularly discharge arrangements.
Verbatim wording from the response “4. The Council has initiated a review of how Adult Care Mental Health workers manage risk within the service. A “Task and Finish Group” was set up in January 2015 to ensure social workers work consistently and robustly in managing risk to include compliance with SDS procedures, including where a person is discharged. This Group will also work collaboratively with the Trust and other Health colleagues where appropriate. In addition, the Council intends to email all relevant fieldwork staff with a reminder of the SDS processes, particularly the arrangements to be followed on discharge.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit a sample of recently closed cases to confirm adherence to the Self-Directed Support discharge procedure.
Verbatim wording from the response “6. To ensure there is consistency across all cases, an audit will be undertaken in respect of a sample of recently closed cases to confirm adherence to the SDS discharge procedure. This will better inform Adult Care senior management as to whether further staff training is required.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Care Programme Approach and Discharge, Transfers/Transition Policies with clearer discharge-planning and GP-communication guidance.
Verbatim wording from the response “8. A plan has been agreed to update the Care Programme Approach Policy and Discharge, Transfers/Transition Policy to provide clearer updated guidance upon discharge planning particularly in relation to communications with GPs.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review how Adult Care Mental Health workers manage risk through a Task and Finish Group, including compliance with Self-Directed Support discharge procedures.
Verbatim wording from the response “4. The Council has initiated a review of how Adult Care Mental Health workers manage risk within the service. A “Task and Finish Group” was set up in January 2015 to ensure social workers work consistently and robustly in managing risk to include compliance with SDS procedures, including where a person is discharged. This Group will also work collaboratively with the Trust and other Health colleagues where appropriate. In addition, the Council intends to email all relevant fieldwork staff with a reminder of the SDS processes, particularly the arrangements to be followed on discharge.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-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 Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.
Verbatim wording from the response “4. The Council has also established that there is still some work to be done in terms of education for health and social care workers on the expectations of each service pathway. The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the PARIS discharge-letter format after the audit and determine necessary changes.
Verbatim wording from the response “11. On completion of the audit, a review of the discharge letter format available within the PARIS system will take place and it will be amended accordingly. New templates will be configured which will alert GPs to information they should enter onto the ‘special patient notes’ facility.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.
Verbatim wording from the response “In order to address these concerns the Council and DCHFT intend to review:-” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.
Verbatim wording from the response “2. Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where a social worker is the lead practitioner. The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing SDS policy, if correctly applied, ensures discharge letters identify reasons and risk triggers for reassessment and possible support reinstatement.
Verbatim wording from the response “5. The Council is satisfied that, if applied correctly, the existing policy would ensure that upon discharge a letter would be written to the client’s GP setting out the reasons for the discharge decision and would identify any risk triggers and indicators to ensure that there would be a re-assessment and possible reinstatement of support if there are signs of a deterioration in mental health.” Source location 2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Open published response
1 Nov 2013 Rachael Claire Slack and 2 others · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Failure to exchange relevant information between Police and Mental Health Services 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
Rachael Claire Slack and 2 others · 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
On 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.
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 Derbyshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to exchange relevant information between Police and Mental Health Services
Wider context from the report “1. At the time of arrest of Mr Cairns, the Police were aware of his assessment under Section 136 of the Mental Health Act the previous day. The Custody Nurse had contacted the Crisis Team to obtain information regarding the 136 assessment which was duly given by the Mental Health Team. However, there was no reciprocal exchange of information and the Mental Health Team were not informed that Mr Cairns had been arrested with regards to Threats to Kill his partner.
2. At the conclusion of the Inquest and after all the evidence was heard, it came to light that there was in existence a policy for mutual sharing of information between the Police and Mental Health Services if each respective organisation requested information from the other.
3. This document was not disclosed prior to the Inquest or during the Inquest itself and it would have been critical to ask witnesses from the Police and Mental Health Services about their knowledge of this document.
” 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