15 Feb 2024 Thomas Peter LOXTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of collaborative working to establish and embed the process for notifying of patient deaths View source Failure to complete BCH Root Cause Analysis recommendations within their target timeframes View source Failure to complete the patient-death notification process action within its target timeframe View source Lack of collaborative working to establish and embed the process for notifying of patient deaths View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Peter LOXTON · 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
Thomas Peter LOXTON was found unresponsive at home on 21 September 2023 and was subsequently declared deceased. The post-mortem examination determined that his death was due to an overdose of multiple prescription medications, and the inquest concluded suicide. Concerns included administrative errors that led to clinicians sending contact letters to his family after his death, insufficient collaborative working between two mental health trusts, and outstanding actions intended to reduce the risk of future deaths.
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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of collaborative working to establish and embed the process for notifying of patient deaths
Wider context from the report “2. Secondly, in this inquest, there was evidence that Thomas' family received letters from clinicians from Dudley Integrated Health and Care NHS Trust (DIH) requesting that Thomas made contact, which were sent after his death, causing obvious distress to his family. It is not difficult to see that this type of administrative error could lead to significant distress to families who are already vulnerable by virtue of their bereavement, and which could give rise to a risk of death. An RCA carried out by DIH identified that action was to be taken - namely that DIH should work with colleagues at BCH to establish and embed the process for notifying of patient deaths . However, this does not appear to be an action that has been identified in BCH's RCA report , and I am concerned by the apparent lack of collaborative working to ensure this process is carried out .
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete BCH Root Cause Analysis recommendations within their target timeframes
Wider context from the report “1. The evidence on behalf of Black Country Healthcare NHS Foundation Trust (BCH) was that there are numerous recommendations as detailed in its Root Cause Analysis (RCA) report that remain outstanding that have target completion dates that arise after the conclusion of this inquest. These dates have been pushed back once already . I am concerned that if these targets are pushed back further and/or are not met , for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that the targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the patient-death notification process action within its target timeframe
Wider context from the report “2. Secondly, the evidence on behalf of DIH was that the above action to be taken remains outstanding and has a target completion date that arises after the conclusion of this inquest . I am concerned that if this target is pushed back and/or is not not met , for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that the targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of collaborative working to establish and embed the process for notifying of patient deaths
Wider context from the report “1. In the inquest, there was evidence that Thomas' family received letters from clinicians from Dudley Integrated Health and Care NHS Trust (DIH) requesting that Thomas made contact with them, which were sent after his death, causing obvious distress to his family. It is not difficult to see that this type of administrative error could lead to significant distress to families who are already vulnerable by virtue of their bereavement, and which could give rise to a risk of death. An RCA carried out by DIH identified that action was to be taken - namely that DIH should work with colleagues at Black Country Healthcare NHS Foundation Trust (BCH) to establish and embed the process for notifying of patient deaths . However, this does not appear to be an action that has been identified in BCH's RCA report , and I am concerned by the apparent lack of collaborative working to ensure this process is carried out .
” 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 Engage DIH-managed GP practices to identify further opportunities to improve death-notification processes.
Verbatim wording from the response “• In addition, we recognise that a patient’s GP will often be best placed to receive death notifications, reflective of their role as being at the heart of individual patient care. However, it is not always possible for each GP to be able to easily recognise all of the relevant organisations which would require being informed.
Both DIH & BCH have therefore raised this issue with our local Black Country ICB to explore how we might be able to better manage this with our primary care colleagues.
Within DIH, we have also engaged with our own GPs – we manage two GP practices in Dudley – to help identify any further opportunities for improvement.” Source location Response from Dudley Integrated Health and 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 the implemented changes at regular intervals to ensure they remain embedded.
Verbatim wording from the response “I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 response very seriously and will continue to take action to reduce the likelihood of a similar incident from reoccurring. We hope that the actions highlighted above will make a difference and we will review changes made at regular intervals to ensure that they are embedded whilst sharing the outcome and lessons learnt with all affected staff.” Source location Response from Dudley Integrated Health and 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 Ensure the immediate death-notification changes are reflected in DIH’s relevant procedural documents.
Verbatim wording from the response “In addition, we are both ensuring that these immediate changes are now being appropriately reflected in the relevant procedural documents within each organisation.” Source location Response from Dudley Integrated Health and 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 Raise death-notification coordination with the Black Country ICB to explore improved management with primary care colleagues.
Verbatim wording from the response “• In addition, we recognise that a patient’s GP will often be best placed to receive death notifications, reflective of their role as being at the heart of individual patient care. However, it is not always possible for each GP to be able to easily recognise all of the relevant organisations which would require being informed.
Both DIH & BCH have therefore raised this issue with our local Black Country ICB to explore how we might be able to better manage this with our primary care colleagues.
Within DIH, we have also engaged with our own GPs – we manage two GP practices in Dudley – to help identify any further opportunities for improvement.” Source location Response from Dudley Integrated Health and 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 Explore with relevant colleagues how full implementation of local medical examiner services could improve death-notification processes.
Verbatim wording from the response “• We have also identified that the full implementation of local medical examiner services also provides an excellent opportunity to improve the death notification process for all organisations and so are also exploring this with the relevant colleagues.” Source location Response from Dudley Integrated Health and 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 Routinely contact BCH after an unexpected adult patient death to check whether BCH knew of the death and had patient involvement.
Verbatim wording from the response “Building on the collaborative working arrangements we already have in place between DIH & BCH, with immediate effect, we have implemented a more enhanced process in both organisations to try to minimise any opportunities for delay and the impact this might have on families, as well as identified some broader actions to help develop further improvements:” Source location Response from Dudley Integrated Health and Care NHS Trust
Open published response
30 Nov 2017 Ms Penelope Benton · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to communicate previous tramadol overdose information to the General Practitioner on the hospital discharge letter View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Penelope Benton · 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
Ms Penelope Benton, who had a history of paranoid schizophrenia, self-harm and significant pain, died on 12 July 2017 after taking a significant quantity of Tramadol. The principal concern was that her previous Tramadol overdose was not recorded in the hospital discharge letter and was therefore not communicated to her GP, who continued prescribing Tramadol.
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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate previous tramadol overdose information to the General Practitioner on the hospital discharge letter
Wider context from the report “1. Evidence emerged during the inquest that the General Practitioner wasn’t made aware of the previous tramadol overdose on the discharge letter from Hospital .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review standards for discharge communications.
Verbatim wording from the response “As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharging communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary.” Source location 2017-0349-Response-by-Dudley-and-Walsall-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 Reiterate to medical staff the importance of including necessary incidents and risk factors in discharge letters.
Verbatim wording from the response “As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharging communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary.” Source location 2017-0349-Response-by-Dudley-and-Walsall-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 Agree required audit frequency and standards for discharge communication, then communicate them to medical teams.
Verbatim wording from the response “It should also be noted that consultant teams also undertake audits in relation to the quality of discharge letters and communication with GPs to ensure / monitor the quality of discharge communication and ensure that the standard of these letters remains high. A required frequency / standard of audit and checking will be agreed as part of this review” Source location 2017-0349-Response-by-Dudley-and-Walsall-NHS-Trust
Open published response
7 Sep 2016 Glen Jordan · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to safely balance removal and retention of patients’ personal items in rooms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Glen Jordan · 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
Glen Jordan, who had a history of depression and suicidal thoughts, was admitted to Bushey Fields Hospital as an informal patient on 20 April 2016. He was found hanging with the strap from a holdall in his room at around 2am on 24 April 2016 and died shortly afterwards. The principal concern was the balance between removing potentially hazardous personal items and allowing patients to retain personal belongings under least restrictive policies; the inquest also identified a failure to respond to an obvious risk of self-harm.
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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to safely balance removal and retention of patients’ personal items in rooms
Wider context from the report “1. Evidence emerged during the inquest that the holdall bag with the attached strap was left in his room after being checked by staff . There is a fine balance that needs to be reached in terms of removing personal items and allowing patients to keep their personal items within their room as per guidelines for least restrictive policies .
” 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 Complete a multidisciplinary review of inpatient areas, including searches, risk assessments, records and staff responsibilities.
Verbatim wording from the response “In addition, and for further assurance, I would like to inform you that the Trust is in the process of preparing for its Care Quality Commission assessment and, as part of the preparation for this process, a multidisciplinary review of all inpatient areas has been recently undertaken. As part of this review, patients, carers and relatives were spoken to and the inpatient records and case notes were examined. There was a particular focus on searches and risk assessments to ensure they are person centred and effective in the management of the patients presenting risks. I am pleased to say, the outcome of this review was very positive and staff were able to demonstrate to the multidisciplinary team a proficient understanding of their required roles and responsibilities.” Source location Glen-Jordan-Response
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 the revised policies and educate operational staff about the policy changes.
Verbatim wording from the response “Following the ratification and approval of the revised Trust policies, a process for the implementation of the policies has now commenced. This involves educating the operational staff in respect to the changes of the policy and a clinical audit is planned to be” Source location Glen-Jordan-Response
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 Add patients’ bags and cases, including items used to transport belongings, to the search policy’s definition of belongings.
Verbatim wording from the response “I would like to confirm that the Trust search policy is written in line with the requirements of MHA Code of Practice (COP) and, following the conclusion of our investigation, it was ascertained that this had been implemented appropriately. Whilst the policy is unable to be prescriptive in terms of all the items patients can bring into hospital, the Trust acknowledges that items such as removable bag straps may pose a risk to some patients where the patients risk profile and history indicates so. As such, the Trust will include a statement within the policy, that enhances the definition of “belongings” and extend it to include the items that the belongings are actually kept or transported within (i.e. patient’s bags and cases).” Source location Glen-Jordan-Response
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 clinical audit to evaluate the effectiveness of implementing the policy changes.
Verbatim wording from the response “undertaken in April 2017 to evaluate the effectiveness of the implementation of the policy change. (I have also enclosed a copy of the Trust action / implementation plan for your information.)” Source location Glen-Jordan-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the search and clinical-risk policies to clarify staff roles and responsibilities for maintaining patient safety.
Verbatim wording from the response “I would like to confirm that the Trust search policy is written in line with the requirements of MHA Code of Practice (COP) and, following the conclusion of our investigation, it was ascertained that this had been implemented appropriately. Whilst the policy is unable to be prescriptive in terms of all the items patients can bring into hospital, the Trust acknowledges that items such as removable bag straps may pose a risk to some patients where the patients risk profile and history indicates so. As such, the Trust will include a statement within the policy, that enhances the definition of “belongings” and extend it to include the items that the belongings are actually kept or transported within (i.e. patient’s bags and cases).” Source location Glen-Jordan-Response
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 Risk assessments cannot always anticipate every eventuality, limiting the ability to prevent every incident despite responsive safety measures.
Verbatim wording from the response “Whilst remaining fully aware of the constant and continuing risks within mental health provision, the measures and actions taken by the Trust are designed to remind staff about the risks certain additional items can pose in some circumstances. Of course, risk assessments are highly personal and the very best of risk assessments cannot always cover every eventuality (as in this tragic case). Our aim is to reduce the likelihood of a reoccurrence of an incident of this nature, whilst continuing to maintain care that is provided in a dignified, professional and least restrictive manner and in line with our Trust’s visions and values.” Source location Glen-Jordan-Response
Open published response
26 Nov 2014 Amanda Hawkins · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 4 Failure to contact healthcare professionals during missing-person risk assessment View source Failure to direct hospital appointment correspondence to a person able to manage it View source Failure to maintain adequate support during moves, funding changes and step-down of services View source Failure to identify missed essential appointments and provide follow-up View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amanda Hawkins · 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 Hawkins, aged 44, had schizophrenia and experienced multiple moves to accommodation with reduced levels of care and changes in care co-ordination. She was last seen on 30 May 2014 and reported missing that evening; her naked, decomposed body was found on 22 July 2014, and the cause of death was unascertained. Concerns included increased vulnerability following the moves and inadequate follow-up of essential hospital appointments because care co-ordination workers were not informed of missed appointments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact healthcare professionals during missing-person risk assessment
Wider context from the report “(1) When Amanda was reported missing she was classified as medium risk. No contact was made with her healthcare professionals. Had such contact been made earlier in the enquiry her risk profile may well have changed to high risk at an earlier point. This in turn may have led to a different approach in the search for her.
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to direct hospital appointment correspondence to a person able to manage it
Wider context from the report “(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up. Lack of follow up for essential appointments led to her increased vulnerability.
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate support during moves, funding changes and step-down of services
Wider context from the report “(1) The moves following closure of various homes or changes in funding and step down in-services offered to Amanda resulted in her increased vulnerability .
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify missed essential appointments and provide follow-up
Wider context from the report “(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up . Lack of follow up for essential appointments led to her increased vulnerability.
” 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 Copy North CRS outpatient letters to care coordinators.
Verbatim wording from the response “The Trust utilises the Oasis electronic system which logs and records appointments and instances when patients fail to attend. The Trust does however acknowledge that letters from North Community Recovery Service (CRS) medical teams were not copied to the care coordinator or placement provider for them to be aware of the appointments that Miss Hawkins did not attend and therefore no subsequent follow up was made. This is acknowledged as an area of improvement for the Trust which will be managed through the Trust’s embedding lessons processes. Therefore, going forward within CRS North outpatient letters are now copied to the care coordinator and, in addition to this, the Trust has convened a Working Group to look at long term solutions to this issue; this Working Group is being led by the Trusts Head of Recovery Services.” Source location 2014-0516-Response-by-Dudley-Walsall-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 Operate a Working Group led by the Head of Recovery Services to develop long-term solutions for missed-appointment follow-up.
Verbatim wording from the response “The Trust utilises the Oasis electronic system which logs and records appointments and instances when patients fail to attend. The Trust does however acknowledge that letters from North Community Recovery Service (CRS) medical teams were not copied to the care coordinator or placement provider for them to be aware of the appointments that Miss Hawkins did not attend and therefore no subsequent follow up was made. This is acknowledged as an area of improvement for the Trust which will be managed through the Trust’s embedding lessons processes. Therefore, going forward within CRS North outpatient letters are now copied to the care coordinator and, in addition to this, the Trust has convened a Working Group to look at long term solutions to this issue; this Working Group is being led by the Trusts Head of Recovery Services.” Source location 2014-0516-Response-by-Dudley-Walsall-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 Copies of outpatient letters to placement providers are subject to existing consent and information-sharing policies.
Verbatim wording from the response “Where appropriate, consideration will also be given to copies of such letters being sent to placement providers, however this would need to be done in line with existing policies regarding consent and the sharing of information.” Source location 2014-0516-Response-by-Dudley-Walsall-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 panel responsible for the funded care package, rather than the Trust, is responsible for developing risk assessments for prolonged absences from placements.
Verbatim wording from the response “It is the Trust’s view that in cases where there is a history of patients spending a prolonged time out of the placement they reside in, it will be the responsibility of the panel responsible for the allocated funded package of care to develop a risk assessment. The risk assessment would aim to identify how the risk of the patient not returning to the placement could be mitigated and identify what further support can be provided to the patient to enable effective engagement with the community services in a safer and more supportive manner.” Source location 2014-0516-Response-by-Dudley-Walsall-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 step-down placement was clinically appropriate because Miss Hawkins was assessed as able to maintain her safety without further assistance.
Verbatim wording from the response “The investigation/review highlighted that at the time of her placement it was appropriate for Miss Hawkins to reside at Moxley Court as it was felt that the step down in placement was clinically appropriate for Miss Hawkins. She had previously had a consistent care team (from CRS South) with who she generally engaged well with. The clinical appropriateness of this step down is further supported by the fact that Miss Hawkins was assessed as being able to maintain her own safety in the community without the need for further assistance in this regard.” Source location 2014-0516-Response-by-Dudley-Walsall-NHS-Trust
Open published response
3 Jul 2014 Nadine Gillian THURMAN · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to use a neutral approach to family involvement in psychiatric assessments View source Crisis team refusal to allow relatives to be present during assessment 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
Nadine Gillian THURMAN · 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
Mrs Nadine Gillian Thurman was found hanging at home on 5 November 2012, following recent episodes of paracetamol and vodka misuse and hospital treatment. The concerns related to psychiatric assessment, including the exclusion of a relative from contributing and the reported practice of the crisis team refusing relatives' presence.
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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a neutral approach to family involvement in psychiatric assessments
Wider context from the report “My concerns relate to the psychiatric assessment of Mrs. Thurman. ████████ gave evidence to me that he was not allowed to contribute to the assessment. I was told that Mrs. Thurman was asked by a nurse if she was content to be seen on her own. That seems to me to be an approach that is suggestive of the answer and is likely to exclude relevant information. It seems to me that the approach to someone being assessed should be along the lines “Are you happy for your family to be involved in and make a contribution to the assessment”. I was also told by a hospital nurse that on contacting the crisis team to ask if a relative could be present, the crisis team always refuse.
” 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 Dudley Integrated Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Crisis team refusal to allow relatives to be present during assessment
Wider context from the report “My concerns relate to the psychiatric assessment of Mrs. Thurman. ████████ gave evidence to me that he was not allowed to contribute to the assessment. I was told that Mrs. Thurman was asked by a nurse if she was content to be seen on her own. That seems to me to be an approach that is suggestive of the answer and is likely to exclude relevant information. It seems to me that the approach to someone being assessed should be along the lines “Are you happy for your family to be involved in and make a contribution to the assessment”. I was also told by a hospital nurse that on contacting the crisis team to ask if a relative could be present, the crisis team always refuse .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations