12 Dec 2024 Huw Irwin ERASMUS · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure to conduct and understand the requirements of post-leave assessments View source Failure to suitably document post-leave assessment findings View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Develop a revised leave policy addressing risk assessment, documentation, post-leave feedback, and distinct Ground Leave and Section 17 processes.
View source
Action
Audit a weekly sample of patient records to verify that Ground Leave records are completed.
View source
Action
Remind ward staff to document Ground Leave issues and feedback on specific leave conditions in patient records.
View source
Action
Adopt and roll out the revised leave policy across all units.
View source See 1 more action
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AI-generated summary
Huw Irwin ERASMUS · 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
Huw Irwin Erasmus died at Aderyn Unit in Pontypool after consuming a large quantity of Yew leaves while detained under Section 3 of the Mental Health Act. Concerns were raised about the absence of documentary evidence of post-leave assessments, confusion among staff about assessment and documentation requirements, and the failure to identify and manage risks associated with ingesting Yew leaves.
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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 Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and understand the requirements of post-leave assessments
Wider context from the report “The expectation according to the policy and from staff who gave evidence was that Huw would be assessed following a period of leave. It was also anticipated that this assessment would on occasion include a review of whether Huw had ingested vegetation.
There was no documentary evidence in the clinical records that Huw had been so assessed after a period of unescorted leave. There was also confusion amongst staff about the nature of the assessment and the level of documentation required.
Ultimately, the issue was whether in fact these assessments had taken place at all. Although in the circumstances this was not a finding made by the jury, it raises the concern that a failure to understand the requirements of a post-leave assessment and suitably document the findings could result in future deaths.
” 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 Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to suitably document post-leave assessment findings
Wider context from the report “The expectation according to the policy and from staff who gave evidence was that Huw would be assessed following a period of leave. It was also anticipated that this assessment would on occasion include a review of whether Huw had ingested vegetation.
There was no documentary evidence in the clinical records that Huw had been so assessed after a period of unescorted leave. There was also confusion amongst staff about the nature of the assessment and the level of documentation required.
Ultimately, the issue was whether in fact these assessments had taken place at all. Although in the circumstances this was not a finding made by the jury, it raises the concern that a failure to understand the requirements of a post-leave assessment and suitably document the findings could result in future deaths.
” 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 Develop a revised leave policy addressing risk assessment, documentation, post-leave feedback, and distinct Ground Leave and Section 17 processes.
Verbatim wording from the response “Elysium Healthcare’s Leave (including Section 17) Policy, to which reference was made at the inquest, is that which was current in November 2022. Even before the inquest, Elysium Healthcare had been reviewing this policy and I would like to reassure you that the issues you have raised will be incorporated into this review. The new policy will meet the operational needs of all our units (currently we have over 90). We are looking at a range of issues around leave generally, including issues of risk assessment, documentation and post-leave feedback. The new policy will be adopted and rolled out across all our units.” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit a weekly sample of patient records to verify that Ground Leave records are completed.
Verbatim wording from the response “In the interim, whilst the new policy is being developed, we have implemented the following changes in respect of Ground Leave at Aderyn:” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind ward staff to document Ground Leave issues and feedback on specific leave conditions in patient records.
Verbatim wording from the response “In the interim, whilst the new policy is being developed, we have implemented the following changes in respect of Ground Leave at Aderyn:” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt and roll out the revised leave policy across all units.
Verbatim wording from the response “Elysium Healthcare’s Leave (including Section 17) Policy, to which reference was made at the inquest, is that which was current in November 2022. Even before the inquest, Elysium Healthcare had been reviewing this policy and I would like to reassure you that the issues you have raised will be incorporated into this review. The new policy will meet the operational needs of all our units (currently we have over 90). We are looking at a range of issues around leave generally, including issues of risk assessment, documentation and post-leave feedback. The new policy will be adopted and rolled out across all our units.” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient’s leave assessments had taken place, including assessment in multidisciplinary and other staff meetings and documented Ground Leave episodes.
Verbatim wording from the response “Finally, you have raised the issue as to “whether in fact these assessments had taken place at all”. As others may have sight of this response, it is therefore right that I cite the oral evidence that I understand was given at the inquest both by the patient’s Responsible Clinician, Dr Jones, and the Ward Manager, which confirmed that the patient’s Leave was indeed assessed in MDT and other staff meetings. As a result, the patient had had some 84 episodes of Leave at Aderyn without any issues arising in relation to the ingestion of vegetation. This included five episodes of unescorted Ground Leave, which were all the subject of an entry in carenotes providing a comment on the utilisation of that Leave.” Source location Response from Elysium Healthcare
Open published response
Concerns raised 4 Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities View source Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities View source Delays and failures in transferring and acting on discharge clinical documentation View source Lack of agreed minimum information-sharing standards between the Health Board and private psychiatric facilities View source See 1 more concern
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AI-generated summary
Philip David Taylor · 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
Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.
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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 Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities
Wider context from the report “b. There was no joined up planning or joint meeting between the Health Board and Ty Grosvenor prior to the deceased’s discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities
Wider context from the report “a. The Health Board utilises facilities out of area for acute psychiatric care when there are no available beds in the NHS in North Wales. I was informed that the patients, however, remain the responsibility of the Health Board. During the deceased’s time at Ty Grosvenor it does not appear that any/all relevant information was shared between the two organisations e.g. deceased’s progress, medication, treatment etc, except for few telephone conversations.
” 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 Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in transferring and acting on discharge clinical documentation
Wider context from the report “c. The prescription and administration record together with a copy of the pre-admission paperwork were only sent to the Health Board two days after the deceased was discharged .
d. The discharge summary was emailed to the Health Board three days after discharge, but this was either not received by the Health Board or received and not acted upon . In fact, it is the deceased’s wife who had informed the Home Treatment Team that the deceased had been discharged. On knowing this, no one sought to request the discharge summary from Ty Grosvenor , even where there was a change in medication dosage.
” 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 Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed minimum information-sharing standards between the Health Board and private psychiatric facilities
Wider context from the report “e. There was no evidence at Inquest of any written agreement or standard operating procedure or similar between the Health Board and private facility as to minimum standard requirements or expectations between both organisations e.g. what documentation should be shared, how it is to be shared, when documentation should be shared, the timeliness of sharing documentation etc.
f. It is concerning that such minimum standards are not set out and agreed between the Health Board and this private psychiatric unit in a situation where many patients are likely to be treated there. It is not known whether or not such minimum standards or Agreement exists with other out of area private units.
g. In the event that patients are to be treated in private units out of the area then there will be a risk of future deaths if such minimum standards regarding sharing of information and communication are not set and agreed between the Health Board and private facility. There had been no consideration of this as part of the actions arising from the Health Board’s own investigation.
” Open source report
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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 The concern that Elysium failed to share discharge information is factually incorrect; Betsi was informed by telephone and emailed relevant records.
Verbatim wording from the response “Not sharing information except a few telephone calls
That is not a fair reflection of the factual position. The reality is:-” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
Verbatim wording from the response “5. This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of future deaths in relation to the role of Elysium. Mr Taylor was an informal patient and was assessed as low risk. His details were already well known to Betsi who had summarised his position when referring him to Elysium in the first place. They had been informed by” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
Verbatim wording from the response “The Elysium internal policy is to ensure the relevant information is given to home teams so that they can follow up within 72 hours (as was done here). In case it is of assistance to put the issue in context, the contract we have with Surrey requires that information only within 5 days of discharge.” Source location Response from Elysium Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.
Verbatim wording from the response “2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.” Source location Response from Elysium Healthcare
Open published response
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
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
Lewis Charles Francis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elysium Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations