26 Jun 2025 CALLAN NORMAN COLLINS ATKINS · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Failure to enquire about additional resources when the local crisis team has no capacity View source Insufficient mental health crisis team staff capacity for same-day assessment when clinically required 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
CALLAN NORMAN COLLINS ATKINS · 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
Callan was found hanging at his home on 18 May 2023 and was confirmed dead at the scene. The report identified a missed opportunity for a face-to-face mental health assessment the previous day, although it found no possible or probable contribution to his death from this. Concerns were raised that crisis-team staff capacity could determine whether patients were assessed when clinically needed, and that additional resources might not be explored when the team lacked capacity.
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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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire about additional resources when the local crisis team has no capacity
Wider context from the report “That the Trust will not make any enquiries as to additional resources when their local Crisis team has no capacity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health crisis team staff capacity for same-day assessment when clinically required
Wider context from the report “That staff capacity of the mental health crisis team of the Gloucestershire Health and Care NHS Foundation Trust will dictate whether a patient is assessed on the same day when their clinical needs demand the.
” Open source report
8 May 2025 James Oliver Sheppard · Prevention of Future Deaths report Gloucestershire
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Concerns raised 1 Insufficient psychiatric unit bed capacity View source
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AI-generated summary
James Oliver Sheppard · 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 Oliver Sheppard, who had a history of mental health difficulties, died after diving onto the track in front of a train on 27 June 2023. The principal concern was that there appeared to be insufficient beds available in psychiatric units to meet patient demand.
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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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient psychiatric unit bed capacity
Wider context from the report “There appear to be insufficient beds available in psychiatric units to meet patient demand
” 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 Implement measures improving bed-management structure and efficiency and reducing out-of-area placements.
Verbatim wording from the response “We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by ████████, significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
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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 Continue reducing average inpatient length of stay to improve psychiatric bed availability and utilisation.
Verbatim wording from the response “Although bed availability and resourcing continue to present challenges across mental health wards nationally, the measures implemented by the Trust have improved the structure and efficiency of bed management systems and significantly reduced the use of Out of Area Placements over the past three years, clearly demonstrating the Trust commitment towards an ongoing improvement of processes to ensure that every possible effort is made to ensure that those patients who require in-patient mental health care have access to a bed as quickly as possible. Our further work is focused on reducing, wherever possible, the average length of stay of inpatients to ensure that the current number of beds are being used as efficiently and effectively as possible. The Trust will be monitored nationally on this measure as part of NHS England’s Performance Assessment Framework.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
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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 Engage with the local Integrated Care Board on improving local inpatient capacity and access.
Verbatim wording from the response “In its ongoing efforts to improve the position locally, the Trust has also engaged in discussions with the local Integrated Care Board (NHS Gloucestershire ICB) and the development of an inpatient strategy is one of the agreed priorities for the Integrated Care System this year. We will ensure that the importance of adequate access to inpatient care is formally acknowledged through our Contract Management Board meeting with the ICB.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
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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 Commissioning and determining total psychiatric bed resources are responsibilities of the wider local and national health system.
Verbatim wording from the response “We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by ████████, significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
Open published response
21 Feb 2024 Severine Alexia Kelly · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 6 Lack of hospital guidance directing attending paramedics to the correct ward View source Unavailability of a portable landline telephone for emergency communication while remaining with the patient View source Uncertainty about when medical professionals should call the ambulance service View source Failure to update risk assessments and take appropriate action following injurious medical events View source Out-of-date medical training for bank staff View source Failure of AED internal clocks to function View source See 3 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
Severine Alexia Kelly · 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
Severine Alexia Kelly, who was detained under the Mental Health Act and accommodated at Wotton Lawn Hospital, choked on a sandwich provided by hospital staff on 1 October 2022 and died at the hospital. Concerns included out-of-date training for some bank staff, inadequate updating of risk assessments after a previous choking incident, difficulties contacting emergency services, delays in paramedic attendance, uncertainty about when to call an ambulance, and an AED with an apparently non-working internal clock.
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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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital guidance directing attending paramedics to the correct ward
Wider context from the report “A paramedic attending Wotton Lawn hospital was unsure which ward he should attend due to lack of guidance from staff at the hospital . This led to a delay in the paramedic attending on Severine.
” 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a portable landline telephone for emergency communication while remaining with the patient
Wider context from the report “A doctor, attempting to assist Severine and speak to the 999-emergency service was obliged to leave the patient to use a mobile phone. He did not have the facility of a portable landline telephone which would have meant that he could have spoken to the service without leaving 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about when medical professionals should call the ambulance service
Wider context from the report “There seemed to be uncertainty at which stage of a medical emergency a medical professional should call the ambulance service .
” 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments and take appropriate action following injurious medical events
Wider context from the report “Staff needed to be aware of the need to update risk assessments and take appropriate action following a medical event that could be injurious to a patient . Specifically, Severine suffered a similar choking incident in 2021.
” 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Out-of-date medical training for bank staff
Wider context from the report “The medical training of certain “bank” staff , at the hospital on 1 October 2022, was not up to date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of AED internal clocks to function
Wider context from the report “An AED used on the 1 October 2022 appeared not to have a working internal clock .
” 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 Mandate medical review, record updating and risk-assessment updates after medical emergencies that could harm patients.
Verbatim wording from the response “We have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and have produced a practice notice to remind clinical colleagues that, following a medical emergency, the event is reviewed by the medical team/ward Doctor. I can confirm that this has been circulated throughout the site and discussed at team meetings. The notice mandates that following a medical event that has the potential to harm a patient, an entry must be made in the patient record, the medical history and any relevant risk assessment must be updated. The Practice Notice is included as Appendix 1. We will also complete a quarterly audit to ensure that we can evidence this in the healthcare record and the result will be shared with the Hospital Matron.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and circulate guidance requiring staff to direct emergency-service responders to the appropriate ward.
Verbatim wording from the response “As with the 2nd issue, we have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and have produced a practice notice providing clarity with the actions that must be taken when emergency services have been called to attend a medical emergency. I can confirm that this has been circulated throughout the site and discussed at team meetings. The Practice Notice is included as Appendix 2.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit quarterly healthcare records for evidence of post-emergency reviews and updates, and share results with the Hospital Matron.
Verbatim wording from the response “We have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and have produced a practice notice to remind clinical colleagues that, following a medical emergency, the event is reviewed by the medical team/ward Doctor. I can confirm that this has been circulated throughout the site and discussed at team meetings. The notice mandates that following a medical event that has the potential to harm a patient, an entry must be made in the patient record, the medical history and any relevant risk assessment must be updated. The Practice Notice is included as Appendix 1. We will also complete a quarterly audit to ensure that we can evidence this in the healthcare record and the result will be shared with the Hospital Matron.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the medical-emergency escalation process and reinforce it through resuscitation training.
Verbatim wording from the response “We have reviewed the existing process regarding actions to be taken in the event of a medical emergency and believe that this remains fit for purpose, I have attached a copy of the Escalation Procedure Action Card for your information at Appendix 3. This forms part of the Care of the Deteriorating Patient Policy and will be reinforced at all resuscitation training courses. Local escalation procedures are also included as part of the on-site local induction for new starters, therefore, all staff on site should be familiar with the process. In addition, to ensure that staff have a greater awareness of how to respond to a serious choking episode, we have developed a choking simulation to complement the Resuscitation Action Card 5 – Adult Choking (revised in November 2022) which has been included as part of the Level 3 Resuscitation Training from 1 April 2024.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Test portable DECT telephones and establish a permanent hospital telephone solution, using Wi-Fi phones if required.
Verbatim wording from the response “████████ Modern Matron, Wotton Lawn is currently in the process of testing Mitel DECT phones on the hospital site. Portable landlines operate from a base unit, so we need to ensure that these have the range to function effectively at distance from the base unit. If distance proves to be too great in some areas, we have a further option to explore Wi-Fi based phones. We envisage that a permanent solution will be in place by 1 May 2024, and I will write again after this date to provide confirmation.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use bank staff training-compliance information in e-rostering to ensure sufficient trained staff are available for each shift.
Verbatim wording from the response “Additionally, the status of all Bank Staff’s training compliance requirements is available on the e-rostering Allocate System (the system we use to book staff and allocate them to a shift). Matron and ward managers are, therefore, aware of individual’s training compliance. This means that even if some individuals are out of date with their training, the needs of the site as a whole can be met via ensuring that there are sufficient fully trained individuals available each shift to respond to medical emergencies. This system was in place in 2022 but is now more robust due to improvements made to matching locations to bank staff training profiles.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate bank staff work locations into training profiles to support accurate resuscitation training allocation.
Verbatim wording from the response “Currently Clinical Bank staff have ‘Resuscitation Bank’ as an annual requirement on their training profiles and are provided with the option to choose to undertake either Level 2 or Level 3 resuscitation training. The reason they are not presented with just one option is because the LMS has not previously been loaded with their location as we were not able to easily identify where Bank staff are working. However, recent work on this issue means that information regarding their location is now being pulled into Care to Learn, and is going forward we will be able to use this to more accurately allocate the correct level of resuscitation training to their profiles. This means that in future, Bank Staff will only be presented with one option for their training and, therefore, will not have to choose the correct level for their role.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
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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 AED internal clocks are functioning; although they cannot be reset to Greenwich Mean Time, each activation records a timed event log.
Verbatim wording from the response “The AEDs used by the Trust are iPad SP1s supplied by Welmedical. We have liaised with Welmedical and can confirm that the internal clocks on all devices are working but are set at the point of manufacturing. This function cannot be changed by the end user and remains unaffected by any local calibration and replacement battery installation. Importantly though, each time the AED is activated, it keeps a timed log of all events within the episode as with the event involving Miss Kelly. This timed log forms the record of the response, but this record will not necessarily align with Greenwich Mean Time.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing rostering and compliance controls ensure sufficient fully trained staff are available each shift despite some individual training being out of date.
Verbatim wording from the response “Additionally, the status of all Bank Staff’s training compliance requirements is available on the e-rostering Allocate System (the system we use to book staff and allocate them to a shift). Matron and ward managers are, therefore, aware of individual’s training compliance. This means that even if some individuals are out of date with their training, the needs of the site as a whole can be met via ensuring that there are sufficient fully trained individuals available each shift to respond to medical emergencies. This system was in place in 2022 but is now more robust due to improvements made to matching locations to bank staff training profiles.” Source location Response from Gloucestershire Health and Care NHS Foundation 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 existing medical-emergency escalation process remains fit for purpose and is reinforced through training and induction.
Verbatim wording from the response “We have reviewed the existing process regarding actions to be taken in the event of a medical emergency and believe that this remains fit for purpose, I have attached a copy of the Escalation Procedure Action Card for your information at Appendix 3. This forms part of the Care of the Deteriorating Patient Policy and will be reinforced at all resuscitation training courses. Local escalation procedures are also included as part of the on-site local induction for new starters, therefore, all staff on site should be familiar with the process. In addition, to ensure that staff have a greater awareness of how to respond to a serious choking episode, we have developed a choking simulation to complement the Resuscitation Action Card 5 – Adult Choking (revised in November 2022) which has been included as part of the Level 3 Resuscitation Training from 1 April 2024.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
2 Jun 2023 Nigel Harper · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Lack of staff understanding of cross-trust urgent mental health referral procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nigel Harper · 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
Nigel Harper, who had been experiencing severe depression and anxiety and thoughts of self-harm, took an intentional overdose of prescribed sedative and hypnotic medications on 8 July 2022 and died in hospital on 23 July 2022. The report identified a lack of understanding between two NHS Trusts about urgent mental health referrals, resulting in an urgent assessment not being arranged as intended and a continuing risk of similar deaths.
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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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding of cross-trust urgent mental health referral procedures
Wider context from the report “(4) I have concluded that the events described above arose out of a lack of understanding between the two NHS Trusts concerned ( Herefordshire & Worcestershire Health and Care NHS Trust ( HWCT ) and Gloucestershire Health and Care NHS Trust ( GHCT ) ) as to how each other’s mental health services are run – otherwise arrangements would have been made for Mr. Harper’s mental health to be assessed urgently, as was intended.
(5) If staff at HWCT and GHCT do not understand how to make urgent mental health referrals or requests for urgent mental health assessments to each other , there remains a risk that other deaths may occur in similar circumstances in the future.
” 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 Undertake a dip-sample audit of Mental Health Liaison Team referrals in six months to test practice and embed learning.
Verbatim wording from the response “This document is currently in draft but will be ratified at the next Mental Health & Learning Disability Inpatient & Urgent Care Governance & Performance meeting on 7 August 2023. In the interim it is being shared with all members of the team via team meetings and, as such, we will be able to evidence that staff are aware of these important changes. Additionally, in six months’ time, we will undertake a dip sample audit of Mental Health Liaison Team referrals to test our practice and ensure that learning has become embedded.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the revised Mental Health Liaison Team SOP changes with all team members through team meetings.
Verbatim wording from the response “This document is currently in draft but will be ratified at the next Mental Health & Learning Disability Inpatient & Urgent Care Governance & Performance meeting on 7 August 2023. In the interim it is being shared with all members of the team via team meetings and, as such, we will be able to evidence that staff are aware of these important changes. Additionally, in six months’ time, we will undertake a dip sample audit of Mental Health Liaison Team referrals to test our practice and ensure that learning has become embedded.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with the other trust’s senior urgent-care managers and share Crisis Team operational policies to clarify services, referrals and triage.
Verbatim wording from the response “In terms of improving understanding between the two organisations, I can confirm that senior managers from both trust’s urgent care mental health services have met to discuss this matter in detail and shared each other’s Crisis Teams Operational Policies. These documents describe the purpose and scope of the individual services involved and include detail concerning referral and triage.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ratify the revised Mental Health Liaison Team SOP at the scheduled governance and performance meeting.
Verbatim wording from the response “This document is currently in draft but will be ratified at the next Mental Health & Learning Disability Inpatient & Urgent Care Governance & Performance meeting on 7 August 2023. In the interim it is being shared with all members of the team via team meetings and, as such, we will be able to evidence that staff are aware of these important changes. Additionally, in six months’ time, we will undertake a dip sample audit of Mental Health Liaison Team referrals to test our practice and ensure that learning has become embedded.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen the Mental Health Liaison Team SOP by defining referral service agreements, intervention timeframes, confirmation emails, assessment and outcome records, and EPR entries.
Verbatim wording from the response “Our Mental Health Liaison Team has reviewed its SOP and made the following additions under the Discharge section of the document. I enclose a copy for your information and these changes can be seen on Page 17.” Source location Response from Gloucestershire Health and Care NHS Foundation Trust
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
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
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 Gloucestershire Health and Care NHS Foundation Trust; 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 Gloucestershire Health and Care NHS Foundation Trust; 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
11 Feb 2019 Robert Glyn Hughes · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1 Inconsistent application of the triangle of care approach for seeking patient permission to approach the patient’s family View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Glyn Hughes · 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
Robert Glyn Hughes, a 67-year-old man with a history of low mood, alcohol and diazepam dependence, previous overdoses, and prostate cancer, was found deceased at home on 20 February 2018 after police responded to a concerned friend. The report records a concern that the triangle of care approach, involving permission to contact the patient’s family, was not consistently applied.
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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent application of the triangle of care approach for seeking patient permission to approach the patient’s family
Wider context from the report “(1) The triangle of care approach, where mental health team practitioners seek permission from the patient to approach the patient’s family, is not consistently applied.
” 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 practice against the six Triangle of Care standards through executive oversight and Governance Committee monitoring.
Verbatim wording from the response “Our Triangle of Care membership started when the scheme was launched in 2015. Developing our practice to be in line with the six standards expected in the Triangle of Care (https://www.nhsconfed.org/~/media/Confederation/Files/public%20Access/Care Triangle.pdf) has been a dedicated practice development initiative, overseen at Executive level and its progress monitored by our Governance Committee, since that time.” Source location 2019-0042-Response-by-2gether-NHS-Trust
Open published response
Concerns raised 2 Failure to follow up patients after missed mental health appointments View source Lack of clear arrangements for emergency psychiatric referral following presentations involving self-harm, suicidal thoughts or hallucinations 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
MARTIN LEE TILLEY · 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
Martin Lee Tilley had a long history of substance misuse and significant mental health problems, including self-harm discussions, suicidal thoughts, and apparent visual and auditory hallucinations before his last appointment with the Homeless Healthcare Team in July 2017. He was found deceased on 17 October 2017 from the combined toxic effects of prescribed and non-prescribed medication; concerns were raised that there was no evidence of follow-up by the team after July and no answer explaining whether his presentation should have led to an emergency psychiatric assessment or referral to tertiary mental health 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up patients after missed mental health appointments
Wider context from the report “Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team.
Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017.
” 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for emergency psychiatric referral following presentations involving self-harm, suicidal thoughts or hallucinations
Wider context from the report “Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team.
Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017.
” Open source report
Concerns raised 1 Insufficient monitoring of patients’ ongoing conditions by the district nursing service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rose Workman · 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
Rose Workman, a 76-year-old woman with bilateral leg ulcers and other health problems, was admitted to hospital after a general decline, dehydration and leg ulcers. She developed pneumonia and died at 6.15am on 17 June 2016 despite treatment. The report raised concern about whether district nursing services had sufficient measures to monitor patients’ ongoing conditions effectively, noting periods when Rose’s condition was not tracked because of staff shortages and unclear assessment requirements.
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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient monitoring of patients’ ongoing conditions by the district nursing service
Wider context from the report “Whether the district nursing service employs sufficient measures to ensure that patients are effectively monitored of their ongoing condition(s) .
” 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 Operate a capacity-and-demand model to allocate community nursing patients and time appropriately.
Verbatim wording from the response “Workload capacity and its effective management within our clinical services also needs to be satisfactory for patients to be effectively monitored. A “capacity and demand” model was introduced into Community Nursing service in October 2016. This was developed by clinicians and supports the planned and timely allocation of patients who receive care. This resource allocation tool supports suitable time allocation for wound care and colleagues have been strongly advised to apply a rating score and work to a standard operating procedure that supports patient care.” Source location Rose-Workman-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 Issue weighing scales to each locality for pressure-ulcer and malnutrition assessment.
Verbatim wording from the response “Weighing scales have been issued to each locality and where a patients weight cannot be obtained to calculate the MUST score the ulnar measurement is used as advocated by Trust policy.” Source location Rose-Workman-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 Run monthly professional development sessions covering pressure-ulcer risk and malnutrition screening.
Verbatim wording from the response “Our Professional Leads for Community Nursing run monthly Continuous Professional Development sessions for community nurses across the localities; the Braden Risk” Source location Rose-Workman-Response
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 Undertake refresher training on the National Early Warning Score.
Verbatim wording from the response “Refresher training for the National Early Warning Score (NEWS) is being undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward a “deteriorating patient” quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non-qualified clinical workforce to be able to detect a deterioration in a patient’s health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in a standardised way using this evidence based approach for patient care.” Source location Rose-Workman-Response
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 Ratify the combined National Early Warning Score and sepsis policy and use it as cascade teaching material.
Verbatim wording from the response “The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.” Source location Rose-Workman-Response
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 Double Professional Lead and Senior District Nurse capacity for the Gloucester locality.
Verbatim wording from the response “Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally). The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care. We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment.” Source location Rose-Workman-Response
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 Create a combined National Early Warning Score and sepsis management policy.
Verbatim wording from the response “The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.” Source location Rose-Workman-Response
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 Use an unscheduled-care ledger with daily shift-lead oversight of workloads and urgent care demands.
Verbatim wording from the response “An ‘unscheduled care’ ledger (on SystmOne) was also introduced to reduce the impact on those workloads associated with unplanned visits which are referred into our nursing team for an urgent patient contact. This ensures that there are nurses holding the position of shift lead each day and who have an overview of all colleagues’ workloads, demands and unpredicted care requirements.” Source location Rose-Workman-Response
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 Employ an additional District Nurse to support workload and patient care for the relevant team.
Verbatim wording from the response “Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally). The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care. We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment.” Source location Rose-Workman-Response
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 Use the Clinical Lead to embed consistent deteriorating-patient practices across services.
Verbatim wording from the response “The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.” Source location Rose-Workman-Response
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 Drive a deteriorating-patient quality improvement programme to strengthen detection and communication of clinical deterioration.
Verbatim wording from the response “Refresher training for the National Early Warning Score (NEWS) is being undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward a “deteriorating patient” quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non-qualified clinical workforce to be able to detect a deterioration in a patient’s health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in a standardised way using this evidence based approach for patient care.” Source location Rose-Workman-Response
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 Support planned nurse attendance at GP practice meetings and daily links with affiliated practices for complex and high-risk patients.
Verbatim wording from the response “To enhance communications nurses are now supported to attend GP practice based meetings on a planned basis to discuss those patients with more complex needs and those that are identified to be an unplanned hospital admission risk, as well as those at the end of their life. In addition all teams have a process for linking with their affiliated GP practice at least daily, either by telephone or in person. We are also progressing with having more scheduled multidisciplinary cluster meetings which will act as an open forum for nurses, physiotherapists and occupational therapists to discuss and care plan for particular patients on their caseloads.” Source location Rose-Workman-Response
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 Embed Braden, MUST and physical top-to-toe assessments in records, issue clinical guidance and review completion through quality assurance visits.
Verbatim wording from the response “Braden, MUST and physical top-to-toe assessments are now incorporated fully into our clinical record system (SystmOne). For example, for documenting wound care the improved record system provides the facility for wounds to be better described including the date the wounds started, were reviewed and healed. Another example is the top-to-toe assessment which is a question-prompt template with blank boxes for different parts of the body which are required to be completed. Clear professional guidance has been issued to all nurses regarding the need to conduct these assessments at admission to the caseload and re-assessed at a frequency according to need. This clinical practice is now reviewed as part of quality assurance visits across all localities to ensure it is carried out.” Source location Rose-Workman-Response
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 Implement re-engineered electronic records with structured assessments, care planning, deterioration reporting, non-adherence prompts and NEWS/sepsis prompts.
Verbatim wording from the response “Firstly our electronic clinical patient record “SystmOne” has undergone extensive re-engineering with all our community multidisciplinary integrated team “units” (sections of the record split into localities). This re-engineering was clinically led, including” Source location Rose-Workman-Response
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 Produce and operate a structured handover procedure with protected handover time, standard formats and electronic recording.
Verbatim wording from the response “A Standard Operating Procedure for handovers was produced in August 2016, two months after RW’s death. This now provides structure and expectation for handovers within each of our community nursing teams. Time to complete the handover is applied to the SystmOne ledgers previously mentioned and colleagues are strongly encouraged to attend them. A quality review visit has identified that occasionally due to operational pressures nurses have not been able to attend some handovers. However, this is currently being actively monitored by our operational managers to determine whether this is a significant issue.” Source location Rose-Workman-Response
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 Appoint a Clinical Lead for deteriorating-patient practice.
Verbatim wording from the response “The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.” Source location Rose-Workman-Response
Open published response
16 Jan 2017 Shane Dean Hardy · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Lack of information sharing between agencies providing support services View source Failure of services to provide assistance to individuals with addiction and mental health difficulties View source Failure to identify a lead agency for communication 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
Shane Dean Hardy · 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
Shane Dean Hardy, a 29-year-old man with a history of substance misuse and involvement with mental health services, died after placing a belt around his neck and being found hanging from a tree on 8 March 2017. The report raised concerns that people with addiction and mental health difficulties can fall between services, and that agencies supporting an individual may not share information or identify a lead agency for communication.
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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of information sharing between agencies providing support services
Wider context from the report “(2) When multiple agencies are involved in providing support services to an individual, there can be a lack of information sharing between those agencies . No agency is identified as the lead agency for communication purposes.
” 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of services to provide assistance to individuals with addiction and mental health difficulties
Wider context from the report “(1) Individuals who suffer with addiction and mental health difficulties can fall between the services . Mental health services consider it not to be a mental health issue, and refer to alcohol treatment services. If the individual then refuses to engage with the latter, the individual is left receiving no assistance .
” 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 Gloucestershire Health and Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a lead agency for communication
Wider context from the report “(2) When multiple agencies are involved in providing support services to an individual, there can be a lack of information sharing between those agencies. No agency is identified as the lead agency for communication purposes.
” Open source report
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Addressed to Gloucestershire Care Services NHS Trust, now represented here by Gloucestershire Health and Care NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations