30 Mar 2026 Oliver John Roberts · Prevention of Future Deaths report Dorset
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Concerns raised 2 Lack of practical guidance on making communications data applications View source Lack of practical guidance on authorising communications data applications View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Oliver John Roberts · 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
Oliver John Roberts was found suspended by a ligature in a wooded area on 28 January 2024, after being reported missing and after communications data had been requested by police. The principal concern was a lack of practical national guidance for police officers on when and how to make communications data requests, including urgent Grade 2 applications; in this case, the Grade 2 request was submitted almost 24 hours after he was reported missing.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on making communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given.
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016 .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on authorising communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given .
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016.
” Open source report
12 Feb 2026 James Fitzpatrick · Prevention of Future Deaths report Dorset
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Concerns raised 3 Failure to ensure accurate and complete handover information View source Lack of written national guidance for handovers across healthcare settings View source Lack of written local guidance for undertaking and recording handovers View source
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James Fitzpatrick · 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
James Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and complete handover information
Wider context from the report “(4) Two weeks prior to his death, Jim was moved to another ward within Alderney Hospital. There was a verbal handover undertaken which was recorded in the electronic patient records. No written handover was provided. The patient records referred to him being a “high risk of choking” and “on an unofficial soft diet”. This information was not true and was not recorded anywhere else in his records or risk assessments.
(5) Further evidence was given that at the time of Jim’s death there were a number of agency workers at Alderney Hospital, and they would rely on information provided to them at the start of their shift during the handover as they would not have time to go through each patient’s records to appraise themselves of the patient’s history and risks. A daily written handover sheet was provided at the beginning of each shift which would be updated during the day, however from the daily handover sheet provided to the Court for the day of Jim’s death, pertinent general information about Jim was missing from that handover sheet .
(6) The lack of written local and national guidance on the handover of a patient’s care creates a risk that incorrect or incomplete information can be passed to those caring for an individual which may impact upon the patient’s care and may lead to a future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written national guidance for handovers across healthcare settings
Wider context from the report “(1) There is a lack of written national guidance on how handovers between Doctors, Nurses and support staff should be undertaken either when a patient is moved between wards or hospitals, or when there is the handover to staff starting a shift who will be taking over the care of the person. Whilst it is acknowledged that each Trust has different policies and procedures in place, there is no generic national guidance to assist in ensuring relevant, pertinent and critical information is passed on to those who will be caring for the patient .
(2) Evidence was provided that national guidance currently exists in England and Wales for handovers relating to emergency care in acute hospitals, however there is no other guidance for other healthcare settings as to what a handover should include or how it should 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written local guidance for undertaking and recording handovers
Wider context from the report “(3) Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded by those working within the Trust .
” 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 Scope handover processes across all mental health inpatient units by June 2026 to identify required changes.
Verbatim wording from the response “Alongside this immediate action to develop this guidance we have adopted a focus on handovers as a Trust Quality Priority for 2026/27. As part of this work, the first action is to scope the handover processes across all mental health inpatient units by June 2026. This will allow us to understand current approaches, the reasoning behind them, and what changes are required in light of the learning from this inquest whilst we await the new electronic health record. Establishing the Quality Priority for “Improving Inpatient and Transfer of Care Handovers”, means that audits of any incidents relating to concerns regarding handover processes will be reviewed and reported through the Directorate Management Groups for oversight and assurance. The auditing processes will be undertaken between June 2026 and March 2027.” Source location 2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit handover-related incidents across inpatient wards, report findings through governance groups, and monitor progress quarterly through March 2027.
Verbatim wording from the response “Alongside this immediate action to develop this guidance we have adopted a focus on handovers as a Trust Quality Priority for 2026/27. As part of this work, the first action is to scope the handover processes across all mental health inpatient units by June 2026. This will allow us to understand current approaches, the reasoning behind them, and what changes are required in light of the learning from this inquest whilst we await the new electronic health record. Establishing the Quality Priority for “Improving Inpatient and Transfer of Care Handovers”, means that audits of any incidents relating to concerns regarding handover processes will be reviewed and reported through the Directorate Management Groups for oversight and assurance. The auditing processes will be undertaken between June 2026 and March 2027.” Source location 2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise a robust, accurate, live handover function in the pan-Dorset electronic health record planned for 2028.
Verbatim wording from the response “We are committed to ensuring that the development and implementation of the new pan-Dorset electronic health record in 2028 prioritises a robust, accurate, and live handover function to support safe and consistent practice across all services.” Source location 2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and take SBAR-based inpatient handover guidance through internal governance.
Verbatim wording from the response “We are committed to ensuring that the development and implementation of the new pan-Dorset electronic health record in 2028 prioritises a robust, accurate, and live handover function to support safe and consistent practice across all services.” Source location 2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National bodies are responsible for issuing any future community and mental health handover guidance.
Verbatim wording from the response “Trust Response:
Following the concerns raised, we undertook a further review to determine whether any national guidance was in development. At present, we are not aware of any proposed updates or new guidance documents regarding community and mental health handover processes. We await the response from the National Bodies identified in your Regulation 28 report (NICE, GMC,” Source location 2026-0087 - Response from Dorset Healthcare University NHS Foundation Trust
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31 Jan 2025 Alexander Channing · Prevention of Future Deaths report Dorset
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Concerns raised 4 Lack of responsible clinician involvement in discharge planning View source Absence of a policy encouraging repeated proactive approaches to obtaining patient consent for information sharing View source Lack of training for wellbeing services regarding students diagnosed with Emotionally Unstable Personality Disorder View source Failure among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration View source See 1 more concern
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
Alexander Channing · 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
Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of responsible clinician involvement in discharge planning
Wider context from the report “iii. There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a policy encouraging repeated proactive approaches to obtaining patient consent for information sharing
Wider context from the report “iv. There is no policy in place at Devon Partnership NHS Trust which encourages a repeated proactive approach in seeking consent from a patient to share information at relevant times.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for wellbeing services regarding students diagnosed with Emotionally Unstable Personality Disorder
Wider context from the report “i. There is no training provided to the wellbeing services at the Arts University Bournemouth in relation to students diagnosed with Emotionally Unstable Personality Disorder.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure among CMHT staff to recognise direct transfer of patient care between CMHT trusts without prior GP registration
Wider context from the report “ii. There appears to be a failure amongst staff at the Exeter CMHT to appreciate that there can be a direct transfer of a patient’s care to another CMHT trust without the need for a patient to have to first register with a GP surgery
” 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 Provide discharge-planning feedback, including the Coroner’s concerns and the family’s experience, at relevant multidisciplinary team meetings.
Verbatim wording from the response “Following the conclusion of the inquest, feedback was provided at a local level at multi-disciplinary team meetings in the relevant area, this feedback included the concerns expressed by the Coroner and the experience of Alec's family.” Source location Response from Dorset Healthcare NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.
Verbatim wording from the response “Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.” Source location Response from Dorset Healthcare NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.
Verbatim wording from the response “Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.” Source location Response from Dorset Healthcare NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.
Verbatim wording from the response “Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.” Source location Response from Dorset Healthcare NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dorset HealthCare disputes involvement in the discharge planning concerned, stating it was only contacted to arrange a psychiatric outpatient appointment.
Verbatim wording from the response “Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.” Source location Response from Dorset Healthcare NHS
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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 Discharge arrangements are led by the team seeking to transfer care, assigning responsibility to the transferring NHS provider.
Verbatim wording from the response “Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.” Source location Response from Dorset Healthcare NHS
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19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Failure to record out-of-area patients’ identity and relevant circumstances timeously and correctly View source Failure to assess out-of-area patients for available beds when vacancies arise View source Failure to record discussions about allocating available beds to out-of-area patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges was detained under the Mental Health Act and remained in an out-of-area psychiatric intensive care placement for about five months after she was ready for step-down. She died on 26 February 2022 following a ligaturing incident. Concerns included inadequate record keeping and communication, missed opportunities to move her closer to home despite beds being available, and the effects of the prolonged out-of-area placement on her deterioration and death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record out-of-area patients’ identity and relevant circumstances timeously and correctly
Wider context from the report “During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate . Among other things,
1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU.
2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.
During the course of the inquest Dorset Health made the following admission,
Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients , and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed.
Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest.
a) the omission to update the Hospital Overview timeously and correctly.
b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess out-of-area patients for available beds when vacancies arise
Wider context from the report “During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things,
1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU.
2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.
During the course of the inquest Dorset Health made the following admission,
Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed.
Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest.
a) the omission to update the Hospital Overview timeously and correctly.
b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions about allocating available beds to out-of-area patients
Wider context from the report “During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things,
1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU.
2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.
During the course of the inquest Dorset Health made the following admission,
Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed.
Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest.
a) the omission to update the Hospital Overview timeously and correctly.
b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place.
” Open source report
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams 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
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment notes.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment policy .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” 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 Develop and implement a RiO template for Section 12 doctors to send key Mental Health Act assessment information directly to GPs, with corresponding guidance and SOP amendments.
Verbatim wording from the response “This requirement has been considered by ████████ Deputy Chief Medical Officer. You heard during the course of the inquest (and as part of Dorset Council’s evidence) that relevant information and a report following the assessment will be provided to the GP by the Approved Mental Health Professional (AMHP), who is part of and coordinates the assessing team. Dr ████████ has met with his clinical colleagues and it has been agreed that (in addition to this information provided by the AMHP):” Source location Response from NHS Dorset Healthcare University
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 an updated standard operating procedure governing information flow after Mental Health Act assessments.
Verbatim wording from the response “In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.” Source location Response from NHS Dorset Healthcare University
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, approve and disseminate a procedure for supporting patients affected by sexual violence and responding to reported sexual incidents.
Verbatim wording from the response “1. To introduce a Trust procedure that deals with victims of sexual violence when they come onto a ward, in terms of safeguarding them from future incidents / deterioration on the ward. In addition to consider specific guidance for staff as to how to support a patient following a sexual incident.” Source location Response from NHS Dorset Healthcare University
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 Continue implementing the CMHT/STWB interface and screening meetings through an updated standard operating procedure.
Verbatim wording from the response “In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.” Source location Response from NHS Dorset Healthcare University
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 Update RiO training and provide a standalone e-learning module on using the alerts system, promoting it to existing users and staff.
Verbatim wording from the response “In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-learning and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31st October 2022. This training will also be available as a standalone e-learning module, which will be available to all existing RiO users in the Trust. The e-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31st October 2022.” Source location Response from NHS Dorset Healthcare University
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish RiO guidance explaining how to view, add and remove alerts.
Verbatim wording from the response “In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-learning and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31st October 2022. This training will also be available as a standalone e-learning module, which will be available to all existing RiO users in the Trust. The e-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31st October 2022.” Source location Response from NHS Dorset Healthcare University
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 Participate in co-designing a new integrated community mental health operational model through the MHICC transformation programme.
Verbatim wording from the response “It is our belief that the issues highlighted will be addressed through the transformation work that the Trust is closely engaged with, which was touched upon in the evidence of ████████. The NHS Long Term Plan and the Commissioning Framework for Community Mental Health sets out a new vision of mental health support provided by health, social care and voluntary, community and social enterprise (VCSE) organisations, beyond the model of CMHT care. In Dorset, the multi-agency, co-produced project to deliver this vision is known as the Mental Health Integrated Community Care (MHICC) programme. The programme has reached the stage where it is co-designing a new operational model of care, to begin implementation in 2023 / 2024.” Source location Response from NHS Dorset Healthcare University
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 Establish a working group to co-produce, ratify and circulate a Working with Families and Carers policy covering communication, engagement and the Think Family approach.
Verbatim wording from the response “In response to this concern, we will establish a working group led by ████████, Interim Deputy Chief Nursing Officer, to develop a policy on Working with Families and Carers. The policy will cover expectations in respect of communication and engagement with and from families and carers that a patient wishes to involve in their care. The policy will also explain clearly what the Think Family safeguarding approach is and how staff can work within this approach when there are safeguarding concerns. The development of the policy will be a co-produced piece of work between professionals working in services and people with lived experience of using mental health services and of supporting someone living with a mental health condition.” Source location Response from NHS Dorset Healthcare University
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 Update the Safeguarding policy and add appendices covering responses to sexual abuse disclosures in hospital and community settings.
Verbatim wording from the response “████████ has asked me to confirm to you that he is satisfied that he has met this action. The Trust’s Safeguarding policy has been updated to highlight the response needed when an adult discloses they have experienced sexual abuse. This may be in a hospital or community setting. In addition, two appendix documents have been added to the policy setting out further details which I enclose for your reference. ████████ has advised me that the ‘guidance for staff in relation to historical sexual abuse fits in with the ‘Making Safeguarding Personal’ agenda. It’s important to determine what an individual wants to do, while encouraging them and supporting them to report it. Every situation is different so care for patients who disclose historical abuse will be planned on a case by case basis’.” Source location Response from NHS Dorset Healthcare University (3)
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust maintains that the patient did not meet CMHT eligibility criteria at the identified discharge and assessment points.
Verbatim wording from the response “In respect of the care provided to Gaia, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act (“MHA”) in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing (“STWB”) for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury’s conclusions.” Source location Response from NHS Dorset Healthcare University
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 No further action is identified for RiO significant-event flags because their use already forms part of the Trust’s training programme.
Verbatim wording from the response “Please note we have focused our action on the alerts system on RiO. As outlined in the evidence given to you by ████████, there is also a separate function on RiO of flagging a progress note as a significant event, so that it informs the risk assessment. We have not identified any further actions for this function, as this already forms part of our RiO training programme.” Source location Response from NHS Dorset Healthcare University
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers transformation work a more effective response than training staff on the existing CMHT access model.
Verbatim wording from the response “For these reasons and the transformation work being carried out as described in this letter, the Trust does not consider that implementing an action to train Trust staff on the access to CMHT’s would resolve the issues raised.” Source location Response from NHS Dorset Healthcare University
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that staff misunderstand or face ambiguity about accessing community mental health services or discharging patients.
Verbatim wording from the response “I and my team note your concerns that you considered there to be “some ambiguity and inconsistency during the evidence regarding the content of the Integrated Community Mental Health Teams (ICMHT’s) operational policy, and the understanding and application of it”. The Trust team has considered carefully your recommendation that training be provided to all staff on access to Community Mental Health Services, including the process for discharge planning.” Source location Response from NHS Dorset Healthcare University
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 Communication between neurology and psychiatric teams concerns national bodies rather than the Trust, so the Trust will not comment further.
Verbatim wording from the response “I am also grateful to the court for providing clarification that the following specific concern relates to national bodies, as opposed to Dorset Healthcare University NHS Foundation Trust (“the Trust”), and therefore I will not comment further on this as part of my response:” Source location Response from NHS Dorset Healthcare University
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 Reducing the information-feedback timeframe is a decision for Dorset Council and BCP Council, with the Trust able to update its SOP only after agreement.
Verbatim wording from the response “6) As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of the Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours. Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.” Source location Response from NHS Dorset Healthcare University
Open published response
1 May 2022 Ryan Albert Frederick Merna · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 7 Failure to establish where a service user is living View source Failure to document discussion of the response to offensive-weapon disclosures View source Failure to document action taken in response to offensive-weapon disclosures View source Failure to raise offensive-weapon disclosures at Care Programme Meetings View source Failure to contemporaneously document disclosures of possession of an offensive weapon View source Failure to pass offensive-weapon disclosure information to the police View source Failure to investigate disclosures of possession of an offensive weapon View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ryan Albert Frederick Merna · 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
Ryan Albert Frederick Merna died from injuries sustained in a knife attack at his home on 14 August 2016. The concerns included that information about the perpetrator possessing a knife and sleeping rough was not probed, recorded, or raised at a care programme meeting, resulting in a missed opportunity to reassess risk.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish where a service user is living
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document discussion of the response to offensive-weapon disclosures
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response ; the information must be passed to the police; any action taken by the Trust and/or the police to be documented.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document action taken in response to offensive-weapon disclosures
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to raise offensive-weapon disclosures at Care Programme Meetings
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contemporaneously document disclosures of possession of an offensive weapon
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented ; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pass offensive-weapon disclosure information to the police
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police ; any action taken by the Trust and/or the police to be documented.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate disclosures of possession of an offensive weapon
Wider context from the report “1. During the inquest evidence was heard that:
i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping.
ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker.
iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records.
iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure.
2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that
i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain.
ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented.
” Open source report
8 May 2018 Joanne Elizabeth Richardson · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Lack of communication between mental-health care teams about patients' care 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
Joanne Elizabeth Richardson · 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
Joanne Elizabeth Richardson was found suspended by a ligature at her home on 26 September 2017 and the inquest concluded that her death was suicide. Concerns were raised about inadequate communication and lack of joined-up working between mental health teams, which meant important risk information was not shared and could lead to inaccurate risk assessments and a future death.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between mental-health care teams about patients' care
Wider context from the report “iv. The details of that assessment were never referred to the CMHT. They were therefore not aware of how she presented or the risk assessment made by the Steps to Wellbeing Service. This information could have been very valuable to those in the CMHT who assessed her on the 23rd August and 19th September.
v. Evidence was given that some of the Steps to Wellbeing Service have access to DHUFT records, namely RIO records, but not all of them do. Evidence was further given that they do not write entries in these records. Those carrying out assessments therefore are not likely to have access to all information available to DHUFT in relation to the patient.
vi. Further on the 28th August 2017, Mrs Richardson contacted the Crisis Team within DHUFT stating that she had suicidal thoughts of ending her life by hanging. A call was made from the Crisis Team to the CMHT and a Community Psychiatric Nurse was spoken to. There was however no follow up after this, or any written communication with anyone involved in her care.
vii. Valuable information therefore, in relation to a patient, is not being communicated to those involved in the care. There does not appear to be joined up working between the different teams within the Trust. This could therefore lead to inaccurate risk assessments and a future death.
2. I have concerns with regard to the following:
i. That there is a lack of communication between the different teams in DHUFT in respect of a patient's care and as a result there could be the death of a person in the future.
” Open source report
19 Apr 2018 Amanda Mary Spark · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of a policy for supervising all prescribed medication when medication access is identified as a patient risk View source Lack of a policy for communicating medication regime changes and supervision to GPs or other treating practitioners 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
Amanda Mary Spark · 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
Amanda Mary Spark, who suffered with depression, was found collapsed and unresponsive at her home on 3 September 2017 and died from an overdose of prescribed medication. The inquest concluded that her death was suicide. The principal concern was that supervision applied to her mental health medication did not also cover prescribed physical health medication, and that there was no clear policy or communication process addressing this.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for supervising all prescribed medication when medication access is identified as a patient risk
Wider context from the report “iii. Evidence was given that although the GP is written to when there is a change in regime regarding the mental health medication, there is no action taken in relation to the physical health medication. This may be a matter for the GP to resolve but if a patient’s access to medication is to be immediately changed by DHUFT employees, this should be addressed in relation to all medication not just mental health medication .
iv. I heard evidence from the Psychiatric Liaison Team Lead and the Crisis Team Lead that there does not appear to be a policy in place at the Trust to deal with the communication of the supervision of physical health medication. If there is such a policy, they advised me that they are not aware of it.
v. Once the access to medication has been identified as a risk to a patient and there is a need for the taking of it to be supervised, access to, and the taking of, all medication, not just mental health medication, should be supervised.
2. I have concerns with regard to the following:
i. That there is no policy in place in relation to the supervision of prescribed physical health medication when a decision has been made to supervise the administration of prescribed mental health mediation . I would therefore request that DHUFT review their policies regarding the supervision of all medication a patient is prescribed and when and how to alert GPs, or other treating practitioners, regarding changes to mediation regimes and supervision.
ii. If there is already such a policy in place to deal with both physical health and mental health mediation, then I would request that refresher training is undertaken to ensure all staff are made aware of the policy and the procedures to be adapted in such circumstances.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for communicating medication regime changes and supervision to GPs or other treating practitioners
Wider context from the report “iii. Evidence was given that although the GP is written to when there is a change in regime regarding the mental health medication, there is no action taken in relation to the physical health medication . This may be a matter for the GP to resolve but if a patient’s access to medication is to be immediately changed by DHUFT employees, this should be addressed in relation to all medication not just mental health medication.
iv. I heard evidence from the Psychiatric Liaison Team Lead and the Crisis Team Lead that there does not appear to be a policy in place at the Trust to deal with the communication of the supervision of physical health medication . If there is such a policy, they advised me that they are not aware of it.
v. Once the access to medication has been identified as a risk to a patient and there is a need for the taking of it to be supervised, access to, and the taking of, all medication, not just mental health medication, should be supervised.
2. I have concerns with regard to the following:
i. That there is no policy in place in relation to the supervision of prescribed physical health medication when a decision has been made to supervise the administration of prescribed mental health mediation. I would therefore request that DHUFT review their policies regarding the supervision of all medication a patient is prescribed and when and how to alert GPs, or other treating practitioners, regarding changes to mediation regimes and supervision .
ii. If there is already such a policy in place to deal with both physical health and mental health mediation, then I would request that refresher training is undertaken to ensure all staff are made aware of the policy and the procedures to be adapted in such circumstances.
” Open source report
18 Dec 2017 Stephen Mark SHAYLOR · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Reliance on continuous CCTV monitoring to detect prisoner self-harm View source Insufficient stabilisation-wing capacity for inmates needing detoxification View source Intermittent night welfare checks and ACCT observations View source Inadequacy of healthcare night welfare checks for determining whether prisoners are breathing or alive View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Mark SHAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on continuous CCTV monitoring to detect prisoner self-harm
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient stabilisation-wing capacity for inmates needing detoxification
Wider context from the report “(1) There were 38 places available on a corridor in C4 wing as a stabilisation wing for dealing with inmates subject to Healthcare night welfare checks. Head of Residence and Safety told the Court that the Prison received between 60 – 80 inmates per week needing detox and requiring placement in C4 cells which had doors with larger windows for checking patients at night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Intermittent night welfare checks and ACCT observations
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of healthcare night welfare checks for determining whether prisoners are breathing or alive
Wider context from the report “(2) Professor Wall, substance misuse expert, said that the system for looking after these inmates was not fit for purpose and that healthcare night welfare checks (looking through a hatch in a cell door) were inadequate because it was not possible to ascertain if a prisoner was breathing/alive by this method .
” Open source report
13 Dec 2017 Rebecca Jay ROMERO · Prevention of Future Deaths report Avon
View report summary
Concerns raised 6 Lack of training or guidance for staff communicating with young persons by text or social media View source Lack of a clear documented process for in-patient transfers View source Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care View source Lack of guidance for managing children receiving out-of-area psychiatric inpatient care View source Inconsistent terminology and grading in risk assessment View source Failure of care plans to specify dates for meetings and task completion View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rebecca Jay ROMERO · 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
Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance for staff communicating with young persons by text or social media
Wider context from the report “(4) That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear documented process for in-patient transfers
Wider context from the report “(1) In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure . As well as clarifying this process with all providers concerned consideration should be given that a clear documented process is put in place for in-patient transfers so that all those involved understand clearly the situation and the decision made in relation to the 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area . Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children receiving out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area. Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology and grading in risk assessment
Wider context from the report “(3) That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and grading's used to determine the deceased's 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of care plans to specify dates for meetings and task completion
Wider context from the report “(2) Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so agreeing expectations are managed to everyone knows exactly what the plan is and when actions will occur.
” Open source report
Concerns raised 2 Failure to identify unsuitable mattresses for care recipients View source Lack of risk assessment for falls and pressure sore risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify unsuitable mattresses for care recipients
Wider context from the report “(2) It became apparent that the new mattress was not suitable for the deceased and that this had not been adequately identified .
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for falls and pressure sore risk
Wider context from the report “(1) It became apparent that a risk assessment was not completed in relation to the deceased's falls and the pressure sore risk . The deceased was found on the floor after an unwitnessed night by a carer at approximately 4.00 hours. She sustained injuries which subsequently led to her death.
” Open source report
24 Jul 2015 Carl David Roy SMITH · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme View source Deficient information sharing about custodial and welfare checks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carl David Roy 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
Carl David Roy SMITH was found unconscious and without signs of life in his cell at HMP Exeter on 22 November 2012, after being held on remand and receiving medication for seizures and detoxification. His death was concluded to be drug-related, involving methadone toxicity and illicitly obtained methadone. The report identified insufficient custodial and welfare checks and deficient information sharing about those checks for a prisoner on an ACCT and Methadone Stabilisation Programme.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
Wider context from the report “The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficient information sharing about custodial and welfare checks
Wider context from the report “The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient.
” 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 Introduce a robust system for monitoring patients arriving at HMP Exeter who require night welfare checks.
Verbatim wording from the response “6.1. In addition to the Coroners Ruling noted in this report the Trust has introduced a robust system for the monitoring of patients arriving at HMP Exeter and requiring Night Welfare Checks (see appendix 5). This guidance was developed jointly with Public Health England (NTA), HMP Exeter National Offender Management Service and will be approved by NHS England at the Devon Prison Partnership Board in October 2015.” Source location 2015-0298-Response-by-Dorset-Health-Care-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 Review patients on drug treatment programmes jointly with prison staff, agree observation arrangements, and share caseload information.
Verbatim wording from the response “5.5. Concern 1 - To review the systems for Information Sharing reference those on drug treatments stabilisation programmes for Substance Misuse IDTS with Prison Officers so that all Prison Officers are aware of Prisoners concerned.” Source location 2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NOMS at HMP Exeter is responsible for training and auditing operation of the ACCT document system.
Verbatim wording from the response “5.7. Concern 3- To review training and audit the operation of the ACCT document system so that it is made as robust as possible.” Source location 2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The action plan addressed identified care issues, with ongoing compliance audit and executive review providing sufficient assurance.
Verbatim wording from the response “5.1. The Trust recognises that there were failings in relation to Mr Smith’s care, and agrees with both the PPO and HM Coroners view that these issues are of concern. In order to ensure that these issues do not reoccur within the Trust services, an action plan was put into place at the time of receipt of the PPO report into Mr Smith’s death, as the Trust was not the provider at the time of Mr Smith’s death. This action plan assured the Trust that actions taken by the provider at the time of Mr Smith’s death addressed the issues outlined.” Source location 2015-0298-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
13 Apr 2015 Hayden Meirion NORTON · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 3 Unavailability of an emergency code protocol for calling an ambulance View source Lack of recorded blood-pressure monitoring View source Failure to inform inmates about screening for aortic aneurysm View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hayden Meirion NORTON · 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
Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an emergency code protocol for calling an ambulance
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored; or
(2) that he had been informed of a screening test for aortic aneurysm.
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded blood-pressure monitoring
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored ; or
(2) that he had been informed of a screening test for aortic aneurysm.
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform inmates about screening for aortic aneurysm
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored; or
(2) that he had been informed of a screening test for aortic aneurysm .
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” 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 Promote national screening programmes through monthly health-promotion sessions and prison-wide posters.
Verbatim wording from the response “5.5.3. The AAA screening is actively promoted in the prison, as noted in recent audit where of the 29 patients who attended for AAA screening, 18 were self-referrals. (See appendix 5)” Source location 2015-0137-Response-by-Dorset-Health-Care-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 a further audit of hypertension-monitoring compliance in July 2015.
Verbatim wording from the response “5.4.1. National guidelines (NICE) are in place in the Prison healthcare service and form part of the Trusts prison healthcare clinical audit programme. In line with the PPO action plan following the death of Mr Norton, GP Clinical Lead Dr ████████ undertook a baseline review of compliance against NICE QS28 Hypertension to ensure compliance. This is provided at Appendix 3 and at point of audit the Trust was fully compliant. A further audit is planned for July 2015 to ensure ongoing monitoring and compliance.” Source location 2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and track access to abdominal aortic aneurysm screening for eligible Devon prison patients, documenting screening offers, attendance or declining reasons.
Verbatim wording from the response “5.5.1. The Trust now provides a AAA screening programme, which is available to all patients within the Devon prisons. Eligible patients (as defined by the National AAA Screening programme) are tracked to ensure all are offered and receive screening, or reasons for declining are clearly documented.” Source location 2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a baseline review of compliance with NICE hypertension standards for monitoring and recording prisoners’ blood pressure.
Verbatim wording from the response “5.4.1. National guidelines (NICE) are in place in the Prison healthcare service and form part of the Trusts prison healthcare clinical audit programme. In line with the PPO action plan following the death of Mr Norton, GP Clinical Lead Dr ████████ undertook a baseline review of compliance against NICE QS28 Hypertension to ensure compliance. This is provided at Appendix 3 and at point of audit the Trust was fully compliant. A further audit is planned for July 2015 to ensure ongoing monitoring and compliance.” Source location 2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for establishing the prison’s emergency medical response code protocol rests with the Prison Service, specifically HMP Dartmoor’s Governor.
Verbatim wording from the response “3.3. The third of the concerns relates to the HMP Dartmoor service, at the time of this report it is not clear whether the prison have been asked to respond separately or whether the Trust is expected to do so on their behalf. The Trust is awaiting a response from HM Coroner’s office to determine this. For the purposes of this report the third recommendation has been left for HMP Dartmoor Governing Governor Bridie Oaks-Richards to respond to as this is a prison responsibility.” Source location 2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
Open published response
14 Aug 2013 JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient mental health practitioner staffing capacity View source Failure to ensure continuity of the Emotional Wellbeing course View source Failure to complete PHQ9 assessments after antidepressant prescribing View source Failure to share relevant verbal and written risk information with prison staff View source Failure to provide timely follow-up after antidepressant prescribing View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JORDAN ANTHONY BUCKTON · 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
JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.
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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health practitioner staffing capacity
Wider context from the report “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012
Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course. Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency .
Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing. He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure continuity of the Emotional Wellbeing course
Wider context from the report “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012
Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course . Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency.
Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing . He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete PHQ9 assessments after antidepressant prescribing
Wider context from the report “(2) Follow Up After Issue of Anti-Depressant Medication
On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment .
If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated.
The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant verbal and written risk information with prison staff
Wider context from the report “(1) Information Sharing
Mr Buckton had previously hung himself in his cell at Exeter Prison on 14th February 2011 but was saved by prison staff and hospital treatment. He had also committed 3 acts of self-harm within that prison.
At the Inquest none of the wing staff at Portland were aware of his history of such acts nor had they read the C-NOMIS Record of the Potential Identified Risks form.
Evidence was given by medical witnesses that a history of previous self-harm is one of the most significant indicators of a future risk of suicide. This is also recorded in PSO 2700 and in the Self-harm Guidance issued by NOMS.
The jury reported that there was a failure to share verbal and written information within the prison in a suitable manner that all the staff members were informed so as to be able to carry out informed actions.
” 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 Dorset Healthcare University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely follow-up after antidepressant prescribing
Wider context from the report “(2) Follow Up After Issue of Anti-Depressant Medication
On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment.
If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated.
The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”.
” 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