23 Dec 2019 Kieran Luke Hubbard · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure to update the responsible psychiatrist so that the position can be reconsidered View source Abandonment of inpatient bed searches without establishing the information required to consider the request View source Failure to urgently discover and record information required for inpatient bed provision View source Failures in the post-death investigation process View source Unavailability of quick and reliable inter-trust communication for urgent bed placement View source Lack of guidance for advising patients in mental health crisis to stop driving or using machinery View source Failure to expedite the search for and securing of an appropriate inpatient bed View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kieran Luke Hubbard · 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
Kieran Luke Hubbard, who had a history of depressive disorder and recurrent suicidal thoughts, was found dead on 8 February 2019 after hanging himself at a building site. The principal concerns were failures to expedite and properly coordinate an inpatient bed, failures to communicate and escalate the decision to abandon the bed search, inadequate guidance about driving during a mental health crisis, and shortcomings in the post-death investigation.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update the responsible psychiatrist so that the position can be reconsidered
Wider context from the report “5 3 The decision to abandon the search for a bed was taken by healthcare professionals without knowledge of exactly what information, if any, PCFT required to consider the request and without updating the psychiatrist in charge of the deceased care in order for them to consider and reassess the position This appears to be a wholly inappropriate and unsatisfactory position
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Abandonment of inpatient bed searches without establishing the information required to consider the request
Wider context from the report “5 3 The decision to abandon the search for a bed was taken by healthcare professionals without knowledge of exactly what information, if any, PCFT required to consider the request and without updating the psychiatrist in charge of the deceased care in order for them to consider and reassess the position This appears to be a wholly inappropriate and unsatisfactory position
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to urgently discover and record information required for inpatient bed provision
Wider context from the report “5 2 There was a failure by GMMH to fully and properly discover and record urgently or in a timely manner exactly what information was apparently required by PCFT in order to facilitate the provision of a bed. Consequently, there was no opportunity to provide that information and secure in bed which may been available when the deceased had agreed to become an inpatient He was therefore out of hospital and not in a safe and supervised location when he killed himself
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failures in the post-death investigation process
Wider context from the report “5 6 There were failures in the post death investigation process which may result in the true circumstances not being identified and steps taken to prevent continuation or
recurrence of circumstances which may cause or contribute to a future death
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of quick and reliable inter-trust communication for urgent bed placement
Wider context from the report “5.4 If it is not possible to change or alter the "out of area" catchment area for mental health trusts then GMMH and PCFT should ensure that there are quick and reliable methods of communication between to secure a bed as soon as possible If either trust requires further information this too is communicated quickly, recorded and obtained if possible and the trust seeking a placement can make alternative arrangements urgently.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for advising patients in mental health crisis to stop driving or using machinery
Wider context from the report “5 5 There did not appear to be any specific guidance , policy or protocol to assist healthcare staff in advising patients to stop driving motor vehicles or using machinery whilst in a mental health crisis ( in accordance with any DVLA guidance that exists ) which may put themselves or others at risk of death or serious harm
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to expedite the search for and securing of an appropriate inpatient bed
Wider context from the report “5 1 The failure by GMMH to expedite the search for and securing an inpatient bed which a consultant psychiatrist has clinically decided was appropriate to provide a safe and supervised environment for ongoing assessment and treatment for a patient with a serious diagnosed mental disorder who had made a very recent attempt to kill themselves This will also require liaison with PCFT because both trusts will come into contact with one another quite regularly
” Open source report
20 Dec 2019 Tomasz Nowosad · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 21 Insufficient availability of safer cells and CCTV-monitored cells View source Absence of timely, full and accurate clinical record keeping View source Lack of written rationale for self-harm and suicide risk assessments View source Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions View source Inconsistent use of interpretation services during healthcare interviews and ACCT reviews View source Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment View source Inadequate ACCT review during moves from safer cells to ordinary cells View source Failure to maintain auditable cross-shift handover of relevant information View source Failure to provide coordinated interpreted communication about prisoner transfers View source Failure of prison staff to separately record self-harm and suicide risk information View source Observation regimes failing to account for predictable observation patterns View source Failure to review ACCT risk information and escalate concerns on arrival View source Failure to record attendees at healthcare interviews involving prison discipline staff View source Failure of staff to understand transfer rationale and destination suitability View source Failure to review and record relevant developing medical history before clinical interactions View source Failure to ensure prisoners understand transfer reasons and destination regimes View source Failure to identify participating healthcare staff and verify completeness of System One records View source Failure to undertake holistic and updated self-harm or suicide risk assessment View source Failure to hand over relevant ACCT risk information to receiving colleagues View source Failure of receiving-wing staff to attend final ACCT case reviews before transfer View source Failure to make appropriate documentary records for ACCT transfers View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tomasz Nowosad · 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
Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of safer cells and CCTV-monitored cells
Wider context from the report “5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of timely, full and accurate clinical record keeping
Wider context from the report “5 5 It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH mental health staff (whether they be healthcare assistants, nurses or doctors) This is a professional requirement under GMC Good Practice and the NMC code of conduct It is suggested that steps are taken to ensure this is completed in all cases and appropriate audits undertaken to check on this.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written rationale for self-harm and suicide risk assessments
Wider context from the report “5 3 It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there is a written record made of the factors or issues involved in this or what weight or consideration was given to them and how the risk assessment was arrived at It is suggested that it would be appropriate for GMMH and HMPS to ensure that this is introduced
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
Wider context from the report “5 16 It is suggested that it is not appropriate to indicate to a patient prisoner that they are not so ill or vulnerable as others in considering a move out of the HCC because that may influence their cooperation and disclosure of their symptoms and presentation It is suggested that guidance is issued to GMMH staff about this
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of interpretation services during healthcare interviews and ACCT reviews
Wider context from the report “5 4 It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff , and it is suggested that wherever an identified need for the use of this service is recognised it should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, it is essential that every effort is made to ensure that they can understand, so far as it possible, the issues being raised and discussed with them.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Wider context from the report “5 1 The context of this case has to be seen in the light of the fact that in 2019 two self-inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assumptions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document . Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because in many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019
This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of suicide and self-harm We found in particular that staff placed too much emphasis on prisoner’s presentation and did not give sufficient consideration to their risk factors”
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate ACCT review during moves from safer cells to ordinary cells
Wider context from the report “5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain auditable cross-shift handover of relevant information
Wider context from the report “5 11 It is suggested that there should be an auditable process of ensuring that all appropriate information is handed over between different shifts of GMMH and HMPS staff so that there is a continuity and consistency of available information
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coordinated interpreted communication about prisoner transfers
Wider context from the report “5 15 It is suggested that it is not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why they may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prison staff to separately record self-harm and suicide risk information
Wider context from the report “5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Observation regimes failing to account for predictable observation patterns
Wider context from the report “5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review ACCT risk information and escalate concerns on arrival
Wider context from the report “5 9 It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide and how it has been managed to date and whether or not that needs to be reviewed on arrival Any concerns should be escalated
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record attendees at healthcare interviews involving prison discipline staff
Wider context from the report “5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there , but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand transfer rationale and destination suitability
Wider context from the report “5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review and record relevant developing medical history before clinical interactions
Wider context from the report “5 12 It is suggested that GMMH staff should ensure that when they have any clinical interactions with patient prisoners they familiarise themselves with all the developing relevant medical history including recent events and record what they have reviewed or considered
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prisoners understand transfer reasons and destination regimes
Wider context from the report “5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going , particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify participating healthcare staff and verify completeness of System One records
Wider context from the report “5 6 It is suggested that whenever there is a healthcare interaction with a patient prisoner and more than one healthcare member of staff is present, their identities should be recorded and all clinically relevant information is included within the System One records and checked between those present as being full and complete
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake holistic and updated self-harm or suicide risk assessment
Wider context from the report “5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or suicide All staff should be alert to the increased risk of self-harm or suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, including opening an ACCT if necessary However, it is suggested that the list of factors is not exhaustive and everything needs to be considered in light of the overall picture This will usually involve discipline staff and health care staff It is suggested that thereafter, particularly if the prisoner is moved to the HCC, considering all the risk factors and the changing position taking into account the previous recorded history of the prisoner from both a health care and general prison service records This is especially so when ACCTs are being reviewed and a prisoner is being discharged from the ACCT or moved out of the limited number of safer cells available in the prison There has to be consideration of the overall or ‘big picture’ with regards to the risks that the prisoner poses
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over relevant ACCT risk information to receiving colleagues
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of receiving-wing staff to attend final ACCT case reviews before transfer
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate documentary records for ACCT transfers
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Open source report
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Failure of mental health trusts to communicate placement information with private providers and families View source Failure to consider discharge medication and prescribing risk View source Failure of discharge planning to share risk information with GPs and families View source Failure of private providers to obtain relevant clinical information from referring services View source Failure to provide care coordination after placement with a private provider View source Insufficient mental health training and specialist liaison for university welfare staff View source Failure of universities to identify early signs of anxiety and mental health issues in students View source Lack of alternative mental health provision for young adults View source Lack of suitable acute mental health beds for young adults View source Inadequate guidance on glass balustrade safety where climbable furniture is adjacent View source Failure to communicate the change in risk level when patients leave a secure environment View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health trusts to communicate placement information with private providers and families
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement . A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider discharge medication and prescribing risk
Wider context from the report “2. There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU . As a result Hannah was prescribed a month’s supply of medication;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge planning to share risk information with GPs and families
Wider context from the report “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective . Key information was not shared with the GP or the family particularly when care moved back to the family ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of private providers to obtain relevant clinical information from referring services
Wider context from the report “5.The expectations around information sharing with private providers and the expectation on private providers contracted by the NHS to seek information. The Priory did not request any notes from the EDU about Hannah . As a result they were unaware of detailed information held by the Trust regarding previously expressed suicidal ideation ;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide care coordination after placement with a private provider
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and specialist liaison for university welfare staff
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective ;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of universities to identify early signs of anxiety and mental health issues in students
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing . As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage . The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of alternative mental health provision for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative . The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance on glass balustrade safety where climbable furniture is adjacent
Wider context from the report “8. The guidance in relation to the height of glass balustrades where items such as tables, in cafes open to the public including children and other vulnerable people, are placed in close proximity to the glass. The glass balustrade in John Lewis was at a height that accorded with the required standard but by simply climbing onto the table that was adjacent to the balustrade Hannah was able to easily go over the balustrade.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the change in risk level when patients leave a secure environment
Wider context from the report “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family;
” Open source report
29 Mar 2019 Ann Corfield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 5 Delays in prescribing prophylactic anticoagulation for patients at high risk of VTE View source Lack of staff training to administer intravenous fluids in the psychiatric unit View source Failure to provide written handovers containing medication information during patient transfers View source Failure to administer prescribed prophylactic anticoagulation View source Failure to complete fluid balance charts accurately and consistently View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ann Corfield · 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
Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in prescribing prophylactic anticoagulation for patients at high risk of VTE
Wider context from the report “1. I heard evidence that although Mrs Corfield was at high risk of developing a VTE, following her admission to Park House on 28th June, prophylactic anticoagulation was not prescribed for her until 30th June when a prescription for clexane (enoxaparin) was issued. Further, although clexane was prescribed, it was never administered to Mrs Corfield.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training to administer intravenous fluids in the psychiatric unit
Wider context from the report “2. Further, I also heard evidence that the staff at Park House were not trained to administer intravenous fluids . This meant that Mrs Corfield had to be transferred to a North Manchester Hospital for intravenous fluids when she was in urgent need of specialist psychiatric care and treatment. I formed the view that ████████ was left extremely frustrated that he was unable to treat Mrs Corfield with intravenous fluids whilst she was a patient at Park House.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written handovers containing medication information during patient transfers
Wider context from the report “1. I heard evidence at the Inquest staff at Park House were not aware that Mrs Corfield was receiving an anticoagulant in the form of enoxaparin whilst she was a patient at Royal Oldham Hospital to reduce the risk of her developing a VTE or that she had refused this medication whilst a patient ROH . I received written evidence from ████████ that the Pennine Acute Trust has in place an Adult Transfer Policy and a Form should be generated which includes details with regards the patient’s medication and most recent observations. However, the evidence I heard from ████████, Consultant Psychiatrist at Park House, was that this unit still does not receive a written handover .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed prophylactic anticoagulation
Wider context from the report “1. I heard evidence that although Mrs Corfield was at high risk of developing a VTE, following her admission to Park House on 28th June, prophylactic anticoagulation was not prescribed for her until 30th June when a prescription for clexane (enoxaparin) was issued. Further, although clexane was prescribed, it was never administered to Mrs Corfield .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fluid balance charts accurately and consistently
Wider context from the report “2. Dehydration clearly played a part in Mrs Corfield’s death. I heard evidence at Inquest that Fluid Balance Charts were poorly completed indeed some of them were not completed at all or contained errors with simple arithmetic . At the Inquest, I heard conflicting evidence about the usefulness of fluid balance charts. Witnesses who were employed by Pennine Acute Trust tended to place more reliance on the results of blood tests. However, ████████ emphasised to me the importance of FBC charts in a patient like Mrs Corfield who had a history of chronic kidney disease because blood tests were an ‘insensitive measure’ of hydration. I received helpful written evidence from ████████ who is the Divisional Director of Nursing for Medicine at Royal Oldham Hospital, dated 31st January 2019, which, at paragraph 17, shows there are still ongoing problems with the way fluid balance charts are completed some two and a half years after Mrs Corfield’s death.
” Open source report
19 Feb 2019 Janice Andrea Keelan · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 8 Failure to conduct internal review of processes and prioritisation criteria View source Unclear operation of the case prioritisation process View source Failure to provide realistic risk management for bath use by people with mental health conditions View source Failure to account for impaired cognition and probable lack of mental capacity in care and welfare decisions View source Failure to contact the mental health team for assistance when safety work is delayed View source Failure to obtain authority to obtain relevant information from the mental health team View source Failure to urgently prioritise cases involving an apparent risk of death View source Risk of fatal events and scalding injuries during bath use View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Janice Andrea Keelan · 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
Janice Andrea Keelan, who had chronic and complex health conditions and was at risk of falling asleep or having a seizure in the bath, died by drowning on 14 November 2017. A referral for a walk-in shower was not approved until ten days after her death. Concerns included inadequate consideration of her impaired cognition and mental capacity, failure to prioritise the urgent risk, and insufficient action to involve mental health services to reduce the risk of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct internal review of processes and prioritisation criteria
Wider context from the report “3. It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case, or the need to address changes to the prioritisation criteria .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear operation of the case prioritisation process
Wider context from the report “2. It was understood that there was some form of prioritisation process for dealing with these sort of cases, although it was not entirely clear at the inquest hearing how this actually worked, specifically and in detail in practice . The process in this case clearly required urgent prioritisation because of the obvious and apparent risk of death, which MCC were told about at the outset.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide realistic risk management for bath use by people with mental health conditions
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic . Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for impaired cognition and probable lack of mental capacity in care and welfare decisions
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare . The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the mental health team for assistance when safety work is delayed
Wider context from the report “4. The death was potentially avoidable. If for practical reasons the work simply could not have been done prior to 14 November 2017, contact could have been made with the mental health team seeking assistance and advising them of the position so that they could take steps to intervene in order to minimise the risk of a fatality . Sadly, the deceased died just as her daughter feared she might and that is why the application had been made in the first place
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain authority to obtain relevant information from the mental health team
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal. Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath. She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath. This added to the risks to the deceased.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to urgently prioritise cases involving an apparent risk of death
Wider context from the report “2. It was understood that there was some form of prioritisation process for dealing with these sort of cases, although it was not entirely clear at the inquest hearing how this actually worked, specifically and in detail in practice. The process in this case clearly required urgent prioritisation because of the obvious and apparent risk of death , which MCC were told about at the outset .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal events and scalding injuries during bath use
Wider context from the report “1. It must have been apparent that the deceased suffered from fluctuating and impaired cognition and probably lacked ‘mental capacity’ to make decisions about her own care and welfare. The initial assessment on 21 July 2017 clearly demonstrated that she was at significant risk of having an event when using the bath which could prove fatal . Suggesting to a person with the deceased’s mental health conditions that they should not use the bath is completely unrealistic. Her daughter had been struggling to cope with her mother over some years. No apparent thought was given to obtaining authority from the deceased to obtain information from the mental health team to give a fuller picture and a more detailed explanation of the effects of her medication. This also could have produced evidence as to the manifestation of her psychiatric conditions and how, for example, she might have felt the bath was a safe place and a sanctuary from recurring symptoms. There was also clear evidence that the deceased had scalded herself in the bath . She may not have appreciated how hot the water was and people can and do die from scalding burn injuries when using a bath . This added to the risks to the deceased.
” Open source report
Concerns raised 12 Lack of staff training and guidance for supporting prisoners with Asperger’s View source Delays in completing extremism risk assessment reports View source Failure to record and make psychology records accessible to psychologists View source Failure to continue the Care Program Approach after transfer to the Prison Service View source Failure to provide shared access to mental-health and psychology records View source Lack of psychiatric input into care plans View source Failure to escalate medication refusals appropriately View source Failure to provide further psychological input while awaiting transfer View source Lack of a single clear policy for managing medication refusals across weekdays and weekends View source Failure to provide an allocated SIU-based psychologist and continuing psychological input View source Failure to ensure multidisciplinary attendance and formal reports for care-plan meetings View source Inadequate documentary record keeping of care-plan meetings View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Nicky Raymond Reilly · 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
Mr Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and guidance for supporting prisoners with Asperger’s
Wider context from the report “The Court heard evidence as to the increase of prisoners within the Prison Service who potentially have a personality disorder or a degree of Aspergers and the limited services and places available. Of significance was the lack of training or guidance to staff on how to interact or accommodate someone with high functioning Aspergers such as NR. Please note the Court recognises the care provided by the SIU staff and the attempts some staff went to interact with NR, however there was no specific training or assistance given to them .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing extremism risk assessment reports
Wider context from the report “The Extremism Risk assessment work had been concluded by ████████ in May 2016. Despite this, her report had not been completed at the time of NR’s death in October 2016 and she did not anticipate being in a position to complete the report until the New Year, some 8 months later. Whilst there is no evidence that in NR’s case this held up his referral to the Westgate Unit, given that a significant reason for his placement on the SIU prior to placement at Westgate, was to undertake this piece of work, a significant time had elapsed . In the meantime whilst waiting transfer, the Court heard no further Psychological input would be started with NR.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and make psychology records accessible to psychologists
Wider context from the report “The Court received a copy of the psychology records kept by ████████ which the Court heard were the only Psychology records available. It was evident to the Court that there was little to no recording of information within the Psychology department . NR’s psychology medical records were at best, woeful. Moreover, as they were not kept in the Psychology department they were not available access to any other Psychologists .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to continue the Care Program Approach after transfer to the Prison Service
Wider context from the report “Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide shared access to mental-health and psychology records
Wider context from the report “The Court heard how the Mental Health team providing mental health services within HMP Manchester have a completely separate record keeping system (system 1) to the Psychology Team . Whilst acknowledging the Psychologists are employed by HMP Prison Service. However not all the psychologists were forensic psychologists as the Court heard ████████ was a clinical psychologist. There will inevitably be prisoners who require clinical psychological input for a range of diagnosis. Within a community setting such psychological services would be provided by the Mental Health Trust. Hence Psychologists would have access to the patients mental health records within the same Trust, where the same existed.
Where a prisoner is receiving both Mental Health input and Psychological input within a prison, there should be access to the appropriate medical records in order for each service to have a clear understanding of the patients clinical presentations and need. Having access to the totality of the information should then assist in appropriately assessing a patients risk to self and others.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric input into care plans
Wider context from the report “Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate medication refusals appropriately
Wider context from the report “The Court heard evidence as to the lack of action taken by staff following NR's refusal of medication . The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and also weekends. There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned by staff .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide further psychological input while awaiting transfer
Wider context from the report “The Extremism Risk assessment work had been concluded by ████████ in May 2016. Despite this, her report had not been completed at the time of NR’s death in October 2016 and she did not anticipate being in a position to complete the report until the New Year, some 8 months later. Whilst there is no evidence that in NR’s case this held up his referral to the Westgate Unit, given that a significant reason for his placement on the SIU prior to placement at Westgate, was to undertake this piece of work, a significant time had elapsed. In the meantime whilst waiting transfer, the Court heard no further Psychological input would be started with NR .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a single clear policy for managing medication refusals across weekdays and weekends
Wider context from the report “The Court heard evidence as to the lack of action taken by staff following NR's refusal of medication. The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and also weekends . There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned by staff.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an allocated SIU-based psychologist and continuing psychological input
Wider context from the report “NR had been allocated a Psychologist ████████ to undertake the specialist extremism work. However this meant he did not have an allocated psychologist who was based within the SIU .
The evidence to the Court from several witnesses including the Psychologists and SIU staff showed there was confusion as to whom was NR’s allocated Psychologist . The reality was from May 2016, NR received no psychological input and did not have an allocated Psychologist in any meaningful form .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure multidisciplinary attendance and formal reports for care-plan meetings
Wider context from the report “The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentary record keeping of care-plan meetings
Wider context from the report “The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made.
” 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 Rewrite and disseminate medication non-concordance guidance covering escalation after critical medication is missed on weekdays and weekends.
Verbatim wording from the response “The guidance document for staff, for patients who are non-concordant with medication, has been rewritten. The guidance document now makes reference to the actions staff should take if a patient misses critical medication during the weekend as well as during the week. This document was circulated to all staff in December 2018 and has been added to the Trust Health and Justice Intranet for all staff to view.” Source location 2019-0014-Response-by-Greater-Manchester-Mental-Health-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 Audit psychology staff access, records viewed, and clinical entries documented in the system.
Verbatim wording from the response “An audit of psychology access to the system, patients viewed and documented entries made, will be conducted by the Head of Healthcare.
Mental Health and psychology staff now attend the weekly Complex Case meeting, which are minuted, where those prisoners with complex needs are reviewed by the multi-disciplinary team. This allows a multi-disciplinary approach to care planning and a forum for the sharing of information.
HMP Manchester has just received funding from NHS England from the 1st April 2019, to increase mental health services within the prison. Part of this funding will be used to fund a psychologist, employed by Greater Manchester Mental Health Trust, to provide psychoeducationally informed, evidence based specialist support for all those assessed as requiring interventions to address mental health, personality disorder, and support for individuals with learning disabilities.” Source location 2019-0014-Response-by-Greater-Manchester-Mental-Health-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 Inform prison psychology staff how to request access to patients’ NHS clinical records.
Verbatim wording from the response “Where a prisoner is receiving input from the prison psychology team access to the NHS record can be requested by the psychologist responsible for delivering that input to the patient, subject to the normal consent being given. The prison psychology team have been informed of how they can gain access to the patient's clinical record.
Where such access is given, it is expected that the psychologist will document their involvement with the patient in the clinical record, to inform the multi-disciplinary healthcare team of the input that is being provided. Psychology access to the system will allow them to see the current package of care that is being delivered by medical and mental health services.” Source location 2019-0014-Response-by-Greater-Manchester-Mental-Health-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 Require the funded psychologist to document every patient interaction in the patient’s clinical record.
Verbatim wording from the response “As a GMMH employee this psychologist will be expected to document all patient interactions within the patient's system clinical records.” Source location 2019-0014-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Open published response
2 Nov 2018 Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 9 Sub-optimal Mental Health Act assessment performance View source Failure to complete Mental Health Act assessment forms in the required format with the required practitioner information View source Failure to implement a revised Multi Disciplinary Team agenda approach View source Failure to record interim deterioration advice and action information View source Failure to formulate risk clearly and undertake collaborative safety planning View source Failure to obtain collateral histories during Mental Health Act assessments View source Failure to revise and implement the Community Mental Health Team operational procedure View source Failure of mental health liaison practitioners to maintain records, follow systems and protocols, and involve practitioners in decision making View source Failure of operational procedures to ensure nurses' concerns are taken into account in specialist evaluation and detention decisions View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Karl Qolf Jamil Englemak Cassimjee · 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
Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal Mental Health Act assessment performance
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal ;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Mental Health Act assessment forms in the required format with the required practitioner information
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner ;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a revised Multi Disciplinary Team agenda approach
Wider context from the report “2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:
a. The need for the Community Mental Health Team operational procedure to be revised;
b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases ;
c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process;
However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned ;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record interim deterioration advice and action information
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim ).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate risk clearly and undertake collaborative safety planning
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain collateral histories during Mental Health Act assessments
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to revise and implement the Community Mental Health Team operational procedure
Wider context from the report “2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:
a. The need for the Community Mental Health Team operational procedure to be revised ;
b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases;
c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process;
However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned ;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health liaison practitioners to maintain records, follow systems and protocols, and involve practitioners in decision making
Wider context from the report “2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:
a. The need for the Community Mental Health Team operational procedure to be revised;
b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases;
c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process ;
However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned ;
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of operational procedures to ensure nurses' concerns are taken into account in specialist evaluation and detention decisions
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar , to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” Open source report
19 Jan 2018 William Myers · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to circulate important clinical risk information to treating clinicians View source Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist View source Inconsistent continuity of psychiatric care across teams and wards View source Failure to act on recommendations to consider Mental Health Act assessment View source Gaps in clinical record keeping hindering treatment coordination and discharge accountability View source Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist View source Failure of psychiatric consultants to confer sufficiently on a clear management plan View source Insufficient availability of inpatient psychiatric beds for complex individuals View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Myers · 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
William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate important clinical risk information to treating clinicians
Wider context from the report “(3) Valuable background information was not circulated to those involved in his treatment with the result that they were deprived of the crucially important medical history of the potential risks (particularly the attacker was no longer taking the medication which controlled his behaviour and was once again resorted to using illicit drugs). An example of this concerns a 20 page discharge report prepared by a Consultant Forensic Psychiatrist at the time the attacker was being prepared to leave Ashworth High Security Hospital. This report not seem to have been material to the Care Coordinator, the GP nor the Consultant Psychiatrist who undertook treatment on two different psychiatric wards and in the community.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist
Wider context from the report “(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist . Neither of these took place and in consequence warning signs of impending or actual violence were not recognised . Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent continuity of psychiatric care across teams and wards
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy . Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015 . The consultants involved in his treatment did not confer sufficiently to produce a clear management plan.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recommendations to consider Mental Health Act assessment
Wider context from the report “(4) On three occasions during 2015 other clinicians who encountered the attacker recommended that a Mental Health Act assessment be considered with a view to him being detained . These recommendations were not acted upon . Judgements made by Consultant psychiatrists were not acted upon, preferably by a second opinion in the least, but preferably by a Forensic Psychiatrist, as this has been verified by the benefit of hindsight, the attacker's propensity to violent conduct may well have been triggers by a Mental Health Act assessment.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Gaps in clinical record keeping hindering treatment coordination and discharge accountability
Wider context from the report “(5) Gaps in record keeping hindered the coordination of treatment . Examples included a void in the medical notes to explain why the number of letters had been transferred from one psychiatric ward to another (with a different consultant and clinical team), a discharge in his absence (taking place in October 2015) without any record of the assessment having been produced by the same team as to how the risk followed up and why he was to be benefited, nor an explanation as to who had authorised the discharge and the discharge was made.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist . There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of psychiatric consultants to confer sufficiently on a clear management plan
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy. Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015. The consultants involved in his treatment did not confer sufficiently to produce a clear management plan .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of inpatient psychiatric beds for complex individuals
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” 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 Establish strategic patient-flow leadership and review admission and discharge procedures.
Verbatim wording from the response “As part of the new organisation (GMMH) we now have a designated Strategic Lead for Patient Flow who has reviewed the Standard Operating Procedure for managing admissions and discharges. This role includes the following key elements:” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Deliver rolling record-keeping training for Manchester healthcare professionals incorporating lessons from the death.
Verbatim wording from the response “GMMH has developed a rolling programme for all healthcare professionals promoting the importance of good record keeping. This training is currently being delivered across our Manchester services and will incorporate the lessons learned raised following Mr Lound’s death.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Develop forensic in-reach support for high-risk community patients, including timely advice, risk management and second opinions.
Verbatim wording from the response “In addition we are working with colleagues in the Trust’s forensic services to develop in-reach forensic support in the management of high-risk/MoJ patients in the community, especially in areas such as Central West CMHT with a higher proportion of such patients. This will facilitate improved risk assessment and management, forensic opinion and case conferences.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Use patient-flow processes to identify high-risk individuals and minimise multiple-team involvement where clinically appropriate.
Verbatim wording from the response “The Patient Flow Team have responsibility to identify high-risk individuals where the concern regarding continuity of care is heightened and endeavour to admit to an appropriate consultant with previous knowledge of the patient if this is possible and clinically appropriate. It is the role of the Patient Flow team to minimise multiple team involvement and to attempt to ensure that high-risk patients will be admitted under the same team if this is possible.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 care-planning procedures to strengthen continuity and consistent management plans for high-risk individuals.
Verbatim wording from the response “The trust is reviewing all care-planning procedures in the light of the lessons learned from this case to ensure that there is continuity of care and a consistent management plan with particular emphasis on high-risk individuals. Discharge procedures have also been reviewed and high-risk patients should not be discharged without a completed formal discharge care plan and risk assessment with consultant oversight. The discharge care plans will include consideration of the risk of disengagement and non-compliance and the response to these.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
Verbatim wording from the response “The trust is reviewing all care-planning procedures in the light of the lessons learned from this case to ensure that there is continuity of care and a consistent management plan with particular emphasis on high-risk individuals. Discharge procedures have also been reviewed and high-risk patients should not be discharged without a completed formal discharge care plan and risk assessment with consultant oversight. The discharge care plans will include consideration of the risk of disengagement and non-compliance and the response to these.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Identify patients with significant forensic histories in AMIGOS special notes to inform care and discharge planning.
Verbatim wording from the response “Patients with a significant forensic history are now being identified on the newly developed special notes system within AMIGOS the current Electronic Patient Record used in our Manchester services so that individuals presenting will have care plans and discharge plans, which are informed by these risks.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Introduce the approved PARIS electronic clinical record system across Manchester services.
Verbatim wording from the response “GMMH has developed a business case to introduce the PARIS electronic clinical record system bring our Manchester services in line with the wider Trust. This has now been approved by the GMMH Trust Board and will be introduced over the next 12-15 months. This will further enhance accessibility of these assessments to the treating teams.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Strengthen assessment and multidisciplinary discharge processes for service users who go absent without leave.
Verbatim wording from the response “GMMH has ensured careful consideration is being given to the management of service users who go AWOL and the risk assessment process to be carried out prior to a multidisciplinary team discharging them.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Strengthen clinical and operational leadership, consultant supervision and recruitment oversight across Manchester services.
Verbatim wording from the response “There is on-going work to develop a consistent divisional model of service delivery in Manchester. This is designed so that there is enhanced continuity of care for service users by simplifying and rationalising the service model. We have invested in clinical and operational leadership across Manchester to drive forward this consistent clinical model. The operational and clinical leadership of our Manchester service follows the divisional structure e.g. Lead Consultant for North Manchester Community Mental Health Team and Home-based Treatment Team with a Service Manager for North Manchester and Urgent Care.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 cross-service bed-management systems and meetings covering capacity, transfers, discharge planning, incidents and shared learning.
Verbatim wording from the response “• To monitor the use of Adult, Older Adult and PICU inpatient beds and ensure that there are robust bed management systems and process in place across Greater Manchester Mental Health Inpatient services. That there are clear policies and procedures, including bed management meetings to monitor inpatient progress, discharge planning and transfers of care when clinically appropriate.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete caseload reviews covering patient numbers and complexity within the enhanced community model.
Verbatim wording from the response “The Trust transformational work streams have also identified the importance of the enhanced community model. One key element of this is to complete a caseload review in terms of both number and complexity of patients. We have also identified enhanced supervision of caseloads and review of complexity to ensure that workers are appropriately supported. As part of this work we have also identified the need to reduce consultant only caseloads significantly to ensure that the consultants are fully engaged with the multi-disciplinary teams for discussions on zoning, risk and prioritisation of high risk patients.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Reduce out-of-area placements and create local inpatient capacity to limit transfers and preserve continuity.
Verbatim wording from the response “• To reduce the use of Out of Area Placements and create capacity within the Trust Inpatient Services, to enable service users requiring inpatient care to be admitted as close to home as possible. Consistent with their needs, recovery focused and reduce the possibility of service users being transferred between units and teams unless it clinically indicated or in an emergency. We are aware that Out of Area Placements have a significant impact on continuity of care and the reduction of Out of Area Placements is a key work stream for the trust.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Develop a consistent Manchester divisional service model to improve continuity of care.
Verbatim wording from the response “There is on-going work to develop a consistent divisional model of service delivery in Manchester. This is designed so that there is enhanced continuity of care for service users by simplifying and rationalising the service model. We have invested in clinical and operational leadership across Manchester to drive forward this consistent clinical model. The operational and clinical leadership of our Manchester service follows the divisional structure e.g. Lead Consultant for North Manchester Community Mental Health Team and Home-based Treatment Team with a Service Manager for North Manchester and Urgent Care.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-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 Include record-keeping standards in ongoing clinical-staff audit supervision.
Verbatim wording from the response “The importance of good record keeping will form an active part of the ongoing audit supervision of all clinical staff.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Open published response
6 Jan 2018 Marcus Dale Hamilton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to provide sufficient maintenance medication for extended travel 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
Marcus Dale Hamilton · 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
Marcus Dale Hamilton was a long-term service user of Trafford Drug Treatment Services and died from the combined respiratory depressive effects of several drugs taken in slight excess; the conclusion was drug related, with no evidence of deliberate intent. A substantive concern was that, despite planning a 51-day trip to India, he received only a 28-day prescription of MXL and was told he could obtain more there, potentially from the illicit market.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient maintenance medication for extended travel
Wider context from the report “For a number of years MDH was on a maintenance programme with MXL, which he received on a 28 days prescription.
In December 2015 MDH informed GMMH that he was taking a long trip of 51 days, to Goa, India. MDH was advised that he could only have a 28 day prescription of MXL to take with him. He was only given a 28 day prescription along with the necessary documentation for travelling with the drug.
In discussion with the witness from GMMH (MDH’s Recovery Worker) regarding the fact that MDH would clearly run out of his prescription maintenance MXL part way through his holiday the answer I received was that there were drugs in India and MDH would be able to obtain some more MXL. The witness accepted that it could not be certain that MDH (or any other service user) would be able to obtain their maintenance drug (MXL or other) and that such MXL that MDH managed to get hold of would probably have been from the illicit drug market . The same applying to any other service user for whatever maintenance drug.
Whilst I accept that what was said does not likely represent GMMH policy what the witness was telling me was, in fact, the reality of the situation created by GMMHs policy/protocol .
” Open source report
17 Nov 2017 Paul Geoffrey Mullen · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to report prescribed medication non-collection directly to the designated Key Worker View source Failure of the medication non-collection reporting threshold to identify concerns after one or two missed daily collections for reliably compliant patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Paul Geoffrey Mullen · 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
Paul Geoffrey Mullen died at his home in Wigan on 22 June 2017. He had been receiving daily methadone but did not collect it for three consecutive days before his death. The report raised concerns that the pharmacy’s failure to report the missed collections promptly to his designated Key Worker, and the three-day reporting threshold, may have delayed checks on his welfare.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report prescribed medication non-collection directly to the designated Key Worker
Wider context from the report “1. During the Inquest evidence was heard that:-
i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.
ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions. The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.
iii. The Key Worker attached to the deceased was ████████, who is a Key Worker employed by Addiction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker . In the case of the deceased, ████████, the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.
iv. ████████ also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addiction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addiction . The governance of GMMH has no control over Practitioners employed by Addiction and GMMH and Addiction do not share computer reporting systems.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the medication non-collection reporting threshold to identify concerns after one or two missed daily collections for reliably compliant patients
Wider context from the report “1. During the Inquest evidence was heard that:-
i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.
ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions . The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.
iii. The Key Worker attached to the deceased was ████████, who is a Key Worker employed by Addiction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker. In the case of the deceased, ████████, the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.
iv. ████████ also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addiction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addiction. The governance of GMMH has no control over Practitioners employed by Addiction and GMMH and Addiction do not share computer reporting systems.
” Open source report
10 Feb 2017 Rachel Morgan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of clarity about observation levels View source Failure to review observations through a multidisciplinary team View source Failure to initiate timely medication reviews View source Failure to implement enhanced observations for continuing suicide risk View source Failure to complete medication summaries during admission clerking View source Over-reliance on inpatient status as a protective factor in suicide risk assessment View source Failure to conduct full self-harm and suicide risk assessments after concerning incidents View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Rachel Morgan · 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
Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.
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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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about observation levels
Wider context from the report “(4) I am concerned that there is a lack of clarity around the different levels of observations contained within the GMWMHT Observation Policy 2012 . In particular, I draw your attention to the conclusions of the SIR Section 7 Paragraph 8 in which the authors state that “the review team recommend that consideration is to be given by Integrated Governance as to whether there needs to be a statement added to the policy to indicate that intermittent observations can be used for an assessed risk (that is not imminent) or whether the policy provides sufficient clarity in this respect.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review observations through a multidisciplinary team
Wider context from the report “(3) I am concerned that on 2 occasions that observations were considered and/or reviewed were conducted, they were not reviewed by a multi-disciplinary team as per Paragraph 5.4 of the GMWMHT Observation Policy 2012 . Those occasions were on the 12th April 2016 and 15th April 2016 (evening). Please consider further training of all members of staff in relation to the need to engage in a specific risk assessment review process with a multi-disciplinary forum following incidents that raise issues in relation to suicide and self-harm
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate timely medication reviews
Wider context from the report “(1) I am concerned that despite the fact that Rachel Morgan and her family made it clear to the staff at the Medlock Ward from the start of her admission that she wanted her medication to be reviewed as felt that her anti-depressant medication was not working, no steps were taken to begin the review process during the 4 days she was an inpatient before her death . I am concerned that in the knowledge that Rachel was reporting issues with her medication, a medication summary could have been undertaken before the first ward round took place on the 15th April. Please consider whether on admission patients should have a medication summary completed as part of the clerking process, which would allow any medication reviews to be conducted by an appropriate Doctor at the first available opportunity.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement enhanced observations for continuing suicide risk
Wider context from the report “(5) As the Serious Incident Review highlighted, I am also concerned that staff at the Medlock Ward placed an over-reliance on the fact that Rachel was an inpatient as a protective factor. The evidence I have heard confirms the findings of the SIR that during her time on the Medlock Ward Rachel’s feelings of hopelessness and constant thoughts of self-harm did not reduce during her time and although her means for ending her own life were reduced, they were not entirely removed. There was evidence available to nursing staff that could indicated that Rachel was still thinking about ending her life whilst an inpatient and was considering the means that would allow her to do so. The jury have found that this was not adequately addressed by implementing enhanced observations .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete medication summaries during admission clerking
Wider context from the report “(1) I am concerned that despite the fact that Rachel Morgan and her family made it clear to the staff at the Medlock Ward from the start of her admission that she wanted her medication to be reviewed as felt that her anti-depressant medication was not working, no steps were taken to begin the review process during the 4 days she was an inpatient before her death. I am concerned that in the knowledge that Rachel was reporting issues with her medication, a medication summary could have been undertaken before the first ward round took place on the 15th April . Please consider whether on admission patients should have a medication summary completed as part of the clerking process, which would allow any medication reviews to be conducted by an appropriate Doctor at the first available opportunity.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on inpatient status as a protective factor in suicide risk assessment
Wider context from the report “(5) As the Serious Incident Review highlighted, I am also concerned that staff at the Medlock Ward placed an over-reliance on the fact that Rachel was an inpatient as a protective factor . The evidence I have heard confirms the findings of the SIR that during her time on the Medlock Ward Rachel’s feelings of hopelessness and constant thoughts of self-harm did not reduce during her time and although her means for ending her own life were reduced, they were not entirely removed. There was evidence available to nursing staff that could indicated that Rachel was still thinking about ending her life whilst an inpatient and was considering the means that would allow her to do so. The jury have found that this was not adequately addressed by implementing enhanced observations.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct full self-harm and suicide risk assessments after concerning incidents
Wider context from the report “(2) I am concerned that on 2 occasions matters came to the attention of the nursing staff that gave them cause for concern regarding Rachel’s risk of self-harm/ suicide and that neither of these incidents generated a full risk assessment to be conducted . Those incidents were the incident with the Nicorette Inhalator on the 14th April 2016 and the phone call from Rachel’s mother on the 15th April 2016.
” Open source report
Concerns raised 3 Absence of a clear system to safeguard patients pending mental health assessment View source Lack of a reception checklist for identifying and recording mental health and self-harm or suicidal ideation information View source Absence of a clear system for triggering urgent triage and safeguarding steps 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
Nicholas Patrick SULLIVAN · 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
Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.
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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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear system to safeguard patients pending mental health assessment
Wider context from the report “5.2 There was no clear system to trigger urgent triage and safeguarding steps prior to that.
5.3 There was no clear system following triage and mental health assessment referral, to safeguard the patient pending that assessment .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a reception checklist for identifying and recording mental health and self-harm or suicidal ideation information
Wider context from the report “5.1 Whilst recognising that Emergency Departments can by busy, reception staff did not work to a short bullet point pro-forma checklist which identifies issues of mental disorder/conditions and check and record important background issues, such as self-harming behaviour or suicidal ideation . This information is vital to record and should trigger urgent triage/mental health assessment.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear system for triggering urgent triage and safeguarding steps
Wider context from the report “5.2 There was no clear system to trigger urgent triage and safeguarding steps prior to that .
5.3 There was no clear system following triage and mental health assessment referral, to safeguard the patient pending that assessment.
” Open source report
Concerns raised 4 Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission View source Failure to consider DoLS authorisation in the community View source Failure to undertake formal mental capacity assessments in the community View source Failure to formally assess and recognise mental capacity on hospital admission View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leslie Johnson · 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
Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission
Wider context from the report “3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital , but nor did the hospital check or request information from those looking after him in the community . The concern is that in this case, the deceased’s death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider DoLS authorisation in the community
Wider context from the report “1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake formal mental capacity assessments in the community
Wider context from the report “1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess and recognise mental capacity on hospital admission
Wider context from the report “2. Consequently, upon his admission to hospital, it was not recognised that he lacked mental capacity . There was no formal assessment and he was treated as an ordinary patient .
” Open source report
12 Apr 2016 Dennis Bennett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of understanding that DOLS are place specific View source Lack of understanding of the outcome of urgent DOLS applications View source Failure to provide consistent information about DOLS applications View source Failure to distinguish urgent DOLS applications from detention under Section 3 of the Mental Health Act View source Failure to consider whether DOLS are necessary when patients are compliant with treatment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dennis Bennett · 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
Dennis Bennett had dementia and was admitted under the Mental Health Act before receiving end-stage palliative care on a mental health ward, where he died of natural causes on 7 February 2016. Concerns included an urgent deprivation of liberty application made while he was already detained under Section 3, uncertainty about the application’s continuation, confusion about place-specific authorisations, and limited consideration of whether the application was needed while he was compliant and receiving palliative care.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that DOLS are place specific
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific .
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the outcome of urgent DOLS applications
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent information about DOLS applications
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council .
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish urgent DOLS applications from detention under Section 3 of the Mental Health Act
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act .
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider whether DOLS are necessary when patients are compliant with treatment
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests .
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Deliver bespoke Deprivation of Liberty Safeguards training to senior clinical staff, including its relationship with the Mental Health Act and place-specific requirements.
Verbatim wording from the response “The use of DoLs is rare within the Moorside Unit and Bollin/Greenway Ward. In order to ensure staff have a good understanding of the DoLs process and its relationship to the Mental Health Act senior clinical staff will be provided with further bespoke training about DoLs which will incorporate the concerns you raise.” Source location Dennis-Bennett-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 Send Trafford Council a summary email when seeking Deprivation of Liberty Safeguards advice to prevent and promptly correct communication errors.
Verbatim wording from the response “In order to avoid any further miscommunications and because the use of DoLs on the Moorside Unit is rare the Mental Health Administrator has been asked to ensure a summary email is sent to the Council when taking advice. This will ensure any miscommunications are picked up by either party promptly and allow for the correct information to be communicated.” Source location Dennis-Bennett-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 Review end-of-life care and consider the most appropriate legal framework for depriving a patient of liberty.
Verbatim wording from the response “The Trust’s Clinical Improvement Lead Nurse for Dementia, Older People and Carers Services is currently undertaking a review of end of life care. She has been asked to build into the review consideration of the most appropriate legal framework to use.” Source location Dennis-Bennett-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 Require all staff to complete a mandatory Deprivation of Liberty Safeguards training package and monitor completion through the ward manager.
Verbatim wording from the response “I can confirm that in order to ensure all staff have an increased knowledge about DoLs the staff group have been asked to complete a DoLs training package which includes this information. The completion of this training is mandatory and will be monitored by the ward manager.” Source location Dennis-Bennett-Response
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 Trust considers the decision to use DoLS rather than best-interests treatment was available to clinicians in this particular case.
Verbatim wording from the response “Finally, you note Mr Bennett was then on the end stage palliative care and entirely compliant with treatment, there was little consideration as to why a DoLs was applied for as opposed to treating the deceased in his best interests.” Source location Dennis-Bennett-Response
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 Legislation and the code of practice provide no straightforward legal solution when urgent DoLS authorisation expires before standard authorisation is granted.
Verbatim wording from the response “Nationally it is reported that there are an increasing number of situations in which an application for standard and urgent authorisation for DoLs has been made by the Managing Authority but the Supervisory Body has not granted the standard authorisation by the time the urgent authorisation has expired.” Source location Dennis-Bennett-Response
Open published response
9 Dec 2015 Jake Robinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of medication-prescribing capability within substance misuse services View source Failure to identify relevant safety issues in reviews of deaths View source Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm View source Failure to ensure relevant prescribing information is received and communicated to drug services View source Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service View source See 2 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
Jake Robinson · 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
Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medication-prescribing capability within substance misuse services
Wider context from the report “3) The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26. Jake had a good relationship with Phoenix Futures but he did struggle to engage with services. The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify relevant safety issues in reviews of deaths
Wider context from the report “2) The failure to identify the above issue as part of the review into the death of Jake Robinson is a concern as it highlights a missed opportunity to potentially learn lessons .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm
Wider context from the report “4) There was no explanation in the review as to why the appointment clash between Trafford Aim and the Community Mental Health Team led to the appointment with the CMHT being rearranged . Particularly as Jake had made two recent serious attempts of self-harm in July 2015 and was at the very least recognised as a high risk of accidental harm . Given that Trafford Aim were not prescribing Jake at this time the Court had some difficulties in understanding what their role was given that he was also under Phoenix Futures for his substance misuse.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure relevant prescribing information is received and communicated to drug services
Wider context from the report “1) The Court heard evidence that his GP had written to Greater Manchester West on the 23rd June 2015 (exactly to whom this letter was addressed is not known as it was not provided in the evidence from the GP practice) indicating that Jake could be prescribed diazepam following the investigation for his seizure. There was no indication in the review by GM West as to whether this letter had been received and if not why not. However neither of the Drug Services who were involved with Jake were aware of this information and therefore he was not commenced on any benzodiazepine reduction. This issue is being brought to the attention of all the recipients of this Regulation 28 report including the Medical Director for the Greater Manchester NHS Area who will be aware of the same concern raised in a separate recent case.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service
Wider context from the report “3) The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26 . Jake had a good relationship with Phoenix Futures but he did struggle to engage with services. The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties.
” 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 Remind all staff to follow the established protocol by booking eligible service users directly for medical review.
Verbatim wording from the response “As part of the review Trafford Aim identified that Jake should have been booked straight in for a medical review. Instead however, he was booked in for an assessment with a non medical member of staff. This was inappropriate as the assessment provided by Phoenix Futures had been carried out and a clear need for a medical review established. All staff have been reminded of the established protocol.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-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 Continue highlighting through training and local guidance the importance of inviting relevant agencies and professionals to serious incident reviews.
Verbatim wording from the response “The Trust encourages reviewer leads to give all parties, who maybe involved in the serious incident, the opportunity to be involved in Serious Incident Review process, including GPs. If the reviewers had invited the GP to contribute to the process and the GP took this opportunity, it is likely the issue of the missing letter would have come to light and been included in the review. The Trust will continue to highlight to review leads through training events and local guidance the importance of ensuring all key agencies and professionals such as GPs are invited to contribute to the GMW review process where appropriate.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-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 Operate the Dual Diagnoses Steering Group to develop partnership working, joint assessment and joint casework across relevant services.
Verbatim wording from the response “The Trust acknowledge that whilst this process and close working relationship between Trafford Aim and Phoenix Futures exist, the disjointed nature of the commissioned services is not ideal. The Trust had developed a Dual Diagnoses Steering Group to review how the services and mental health services work together. There has already been two planning meetings. The aim is to ensure effective partnership working by collocating services, effective joint assessment and joint working of cases with dual diagnosis.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-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 Streamline receipt procedures for letters and faxes to reduce opportunities for them to be lost.
Verbatim wording from the response “Trafford Aim however have taken the opportunity to review their administration process regarding receipt of letters and faxes sent to the service. A more streamlined process has been put in place which has reduced the points at which a letter or fax may get lost.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-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 Maintain an established protocol enabling under-25 service users needing medication review to access Trafford Aim quickly.
Verbatim wording from the response “The number of service users under the age of 25 who require medical intervention and treatment for a drug problem is very small. However, the Trust recognises that on occasion this can occur and has an established protocol between both services that allows those service users under the age of 25, who require a medicines review, to quickly assess the service. All efforts to reduce duplication and streamline the pathway for the service users are made.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-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 service was unaware of the fax because the GP did not alert the recipient or confirm that it had been received.
Verbatim wording from the response “I can confirm that the Serious Incident Review Team and Trafford Aim were unaware that a letter had been sent to Trafford Aim until the issue was highlighted in a meeting with the review lead and ████████ after the conclusion of the review. Trafford Aim have carried out a robust search of both its office base and the electronic database and have found no evidence to indicate the faxed letter from the GP had been received.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-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 An established protocol enables under-25 service users needing medication reviews to access the relevant service quickly despite separate commissioning arrangements.
Verbatim wording from the response “Both Phoenix Futures and Trafford are commissioned to meet the needs of different groups of service users however they work closely together.” Source location 2015-0474-Response-by-Greater-Manchester-West-NHS-Mental-Heath-Foundation-Trust
Open published response
11 Mar 2015 LEAH LEVINE · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to clearly define temporary hospital leave conditions, supervision responsibilities and observation requirements View source Failure to document and provide temporary hospital leave arrangements to those taking the patient from hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
LEAH LEVINE · 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
Leah Levine died on 5 October 2014 after getting through a window onto the roof of a house and either jumping or falling. Concerns were raised that the conditions of her temporary leave from hospital, including responsibility for supervision and any observation regime, had not been clearly agreed, documented, or consistently understood by staff.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly define temporary hospital leave conditions, supervision responsibilities and observation requirements
Wider context from the report “When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place : and nothing was reduced to writing and given to those taking her from the hospital.
Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document and provide temporary hospital leave arrangements to those taking the patient from hospital
Wider context from the report “When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from the hospital .
Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the procedure for informal patients’ leave with family and friends by 31 May 2015.
Verbatim wording from the response “I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.” Source location 2015-0093-Response-by-Greater-Manchester-West-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a procedure governing informal patients’ leave with family and friends, including medication, supervision, crisis planning and home-based treatment support considerations.
Verbatim wording from the response “I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.” Source location 2015-0093-Response-by-Greater-Manchester-West-NHS
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 Inform all inpatient nursing and medical staff about the procedure by 31 May 2015.
Verbatim wording from the response “I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.” Source location 2015-0093-Response-by-Greater-Manchester-West-NHS
Open published response
Concerns raised 7 Failure to use CCTV monitoring as an adjunct to ACCT observation procedures View source Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff View source Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits View source Lack of suitably senior psychiatric clinician attendance at discharge case reviews View source Insufficient availability of safer cells across prison wings for prisoners on ACCT View source Unavailability of cells or facilities fitted with CCTV monitoring View source Lack of graduated risk management planning after transfer to an ordinary wing location View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Craig Douglas Bell · 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
Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use CCTV monitoring as an adjunct to ACCT observation procedures
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures . No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
Wider context from the report “2. I am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff . For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff. Appropriate, timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine. It means that clinical staff have to be able to review the clinical record appropriately and share information with their HMPS colleagues.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits
Wider context from the report “1. The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end up deliberately or accidentally killing themselves.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of suitably senior psychiatric clinician attendance at discharge case reviews
Wider context from the report “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting . In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of safer cells across prison wings for prisoners on ACCT
Wider context from the report “5. At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. I am concerned that the prison has a very limited number of safer cells on a limited number of other wings . At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT’s and either transferred from one wing to another or transferred from the HCC to an ordinary wing location ( for what ever reason ) there is no half way house facility providing increased levels of safety . The provision of safer cells has demonstrably reduced the opportunity for fatal self harming in the over whelming majority of cases. Without HMPS investing in the provision of safer cells on every wing or of an increased number of wings there is a concern that prisoners will continue to kill themselves in non safer cells when they are on ACCT’s. The same considerations would apply nationally to the entire HMPS estate.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cells or facilities fitted with CCTV monitoring
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of graduated risk management planning after transfer to an ordinary wing location
Wider context from the report “4. I am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances . This was identified by the clinical reviewer. In other words increased frequency of day time interactions and throughout the whole day and MHIT and Psychiatrist contacts very shortly after the move . In this case the deceased was on the waiting list for a MHIT contact and was due to be seen within 2 weeks by the Psychiatrist.
” Open source report
2 Feb 2015 Kimberley Lauren Lindfield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Lack of a written protocol defining increased observations and required recording View source Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations View source Failure to assign clear responsibility for recording increased observations View source Failure to ensure nursing and clinical staff understand their record-keeping responsibilities View source Lack of written guidance for clinical review and care-plan changes in response to new risks View source Lack of periodic audits of record keeping in similar cases View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kimberley Lauren Lindfield · 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
Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written protocol defining increased observations and required recording
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations
Wider context from the report “1. I am told that all patients presenting with symptoms of mental illness/mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible whether that referral is from A& E or any ward. Pending that assessment, mental health staff can give advice by phone concerning the patients interim care and management. Both UHSM and MHSC provided evidence about a joint understanding and approach as well as a training and induction of staff. GMW may also be involved in such a case. That was to a very large extent the assurance I was provided after the death of Mr Dean. There were no plans or thoughts to audit whether or not in practice there was an appropriate and timely response to such presentations to ensure that the new system was actually working. In view of the history I am concerned that without such an auditing process failures of care may take place as identified above.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clear responsibility for recording increased observations
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done . I am concerned that at present such does not exist .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure nursing and clinical staff understand their record-keeping responsibilities
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written guidance for clinical review and care-plan changes in response to new risks
Wider context from the report “3. I am concerned that there is currently no written protocol or guidance where there is an appropriate clinical review and there should be a change in the care and management plan in response to new or changed circumstances or new risks .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic audits of record keeping in similar cases
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met .
” 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 Provide a single referral pathway with automatic mental health assessment referrals, agreed response times, and interim telephone advice for patients awaiting assessment.
Verbatim wording from the response “The Trafford Rapid Assessment Interface Discharge (RAID) Team began provision of mental health service into UHSM from the 22nd April 2014. The Trafford RAID team provides assessment of Trafford registered patients within UHSM and assessment of Manchester registered patients on all other wards, except for A&E and its associated wards. The Trafford RAID is commissioned to see patients aged 16 and above. Referrals can be taken from any professional within the acute hospital setting who is concerned about a patient’s mental health; included in this are those patients that present with self harming behaviour or suicidal ideas.” Source location 2015-0036-Greater-Manchester-West-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 referral delays monthly with partner organisations and monitor referral-response performance through internal reporting and key performance indicators.
Verbatim wording from the response “Trafford RAID at UHSM has a single referral point for access to a mental health assessment. Trafford RAID have an agreed joint operational procedure with UHSM and MMHSCT that provides clear guidance on access to the mental health practitioners and agreed/commissioned target response times to referrals made to mental (Appendix 1). GMW have key performance indicators agreed by GMW and the NHS Trafford Clinical Commissioning Group, which provides an audit of response times at UHSM on all referrals received. This is evidenced in the performance report submitted to commissioners on a monthly basis. This is audited internally to ensure that standards remain high and to identify areas where improvement is required/learning for the team (Appendix 2).” Source location 2015-0036-Greater-Manchester-West-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 Develop a joint observation procedure and recording charts defining observation requirements, recording arrangements, and staff responsibility.
Verbatim wording from the response “2. Whenever an increased level of observation is initiated, pending a mental health assessment, because of the concern about patients’ mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations involve and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done.” Source location 2015-0036-Greater-Manchester-West-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide parallel mental health assessments for patients requiring medical treatment and arrange review frequencies when sedation or intoxication prevents coherent assessment.
Verbatim wording from the response “GMW Trafford RAID provides parallel assessments when any patients present with mental health needs, e.g. self harm/ overdose but still requiring medical intervention. RAID Team will make face to face contact following referral discussion to complete full assessment, risk assessment or for those patients not appropriate for assessment either due to sedation/intoxication, ascertain and agree frequency of reviews to determine whether state sufficiently improved to undertake coherent assessment. This also provides an opportunity for collective discussion and shared decision making on appropriate management plan for patient.” Source location 2015-0036-Greater-Manchester-West-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 Cooperate with partners to develop an audited process for referrals to mental health liaison teams.
Verbatim wording from the response “In respect of an audited process regarding referrals to mental health liaison teams, we will of course cooperate fully with our colleagues across the local health economy to help develop this. However, since A&E associated ward liaison is provided by MMHSCT, but most other ward liaison services are commissioned from Greater Manchester West (GMW) Foundation Trust’s RAID team, it would seem appropriate that this piece of work is led by UHSM, with the involvement of the two mental health provider organisations.” Source location 2015-0036-Response-by-Manchester-Mental-Health-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide UHSM with advice on developing its self-harm policy and guidance and protocols for observing patients at risk.
Verbatim wording from the response “In respect of the other concerns raised in your report, MMHSCT has agreed to provide UHSM with advice in respect of their development of a self-harm policy and also with their development of guidance and protocols on observation of patients at risk. MMHSCT has suggested that they may wish to build on our existing observation policy.” Source location 2015-0036-Response-by-Manchester-Mental-Health-NHS
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 Existing A&E liaison response targets are closely monitored and performance is regularly scrutinised by the Trust, hospital and commissioners.
Verbatim wording from the response “I appreciate your wish to see a timelier referral to mental health services and, as our services are primarily for A&E, we have set target response times which are closely monitored by UHSM, our Trust and commissioners. There is regular scrutiny of our performance in A&E at several fora, including Executive to Executive meetings with the Manchester Clinical Commissioning Groups, System Resilience Groups and locally with senior managers at UHSM.” Source location 2015-0036-Response-by-Manchester-Mental-Health-NHS
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 UHSM should lead development of the audited mental health liaison referral process, with both mental health providers involved.
Verbatim wording from the response “In respect of an audited process regarding referrals to mental health liaison teams, we will of course cooperate fully with our colleagues across the local health economy to help develop this. However, since A&E associated ward liaison is provided by MMHSCT, but most other ward liaison services are commissioned from Greater Manchester West (GMW) Foundation Trust’s RAID team, it would seem appropriate that this piece of work is led by UHSM, with the involvement of the two mental health provider organisations.” Source location 2015-0036-Response-by-Manchester-Mental-Health-NHS
Open published response
Concerns raised 2 Significant waiting times for access to psychological therapy View source Lack of availability of psychological services within crisis teams 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
Rowena Kathryn Golton · 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
Rowena Kathryn Golton had a history of recurring depression, suicidal thinking and deteriorating mental illness. On 6 April 2014, after being assessed as low risk of suicide and discharged from A&E with a plan for later crisis-team review, she jumped from a fire escape and died from multiple traumatic injuries. Concerns included limited access to psychologists within crisis teams and significant waiting times for psychological therapy.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significant waiting times for access to psychological therapy
Wider context from the report “- Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access.
- In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of psychological services within crisis teams
Wider context from the report “- Evidence was given as to the lack of availability of psychological services within the crisis teams . Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access.
- In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases.
” Open source report
27 Jun 2014 ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients View source Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity View source Failure to use incident reporting and risk-register procedures to identify drug supply or consumption 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
ASHLEY CORIN DE WINTER PONSONBY · 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
Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients
Wider context from the report “1. It is a matter of concern that any ward could be set up and operated involving the inherent risks of drug misuse by dual diagnosis patients without the staff having any training in recognising and dealing with the physical harm and risks arising from the use of illicit substances . The evidence from the independent psychiatrist was that this was an essential ingredient. Consequently, in rehabilitation wards or those with dual diagnosis patients where there is a risk of continuing drug misuse , the concern which arose was that without this, there was a risk of a future death arising. This has implications locally for the Trust, regionally and on a national basis.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity
Wider context from the report “3. There was a concern that a lack of a coherent and mutually understood policy between the Mental Health Trust and the Police as to when they would become involved in illegal activity meant that neither the patients nor the staff had clarity on the position . Just because patients have mental disorder, does not absolve them of all legal responsibilities and indeed understanding and facing possible criminal consequences may be important in their overall clinical management and for the administration of justice. It was suggested that this was being considered by Greater Manchester Police and the local Police and Crime Commissioner, but no policy had yet been finalised . Once again, this has local, regional and national implications, and that the concern is without such policies being formulated and implemented, there is a continuing risk of future deaths which could be prevented.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use incident reporting and risk-register procedures to identify drug supply or consumption
Wider context from the report “2. There is a concern that the failure to use the Datix and Trust incident reporting policy, as well as the risk register (or other similar procedures available to other Mental Health Trusts), to identify the problem of drug supply and/or consumption , if unremedied may lead to a future death. It is a concern both locally for the Trust, regionally and nationally, that such procedures should be appropriately used so as to prevent a future death.
” Open source report
21 May 2014 Mark Darren Bartholomew · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure to retain and make essential observation documentation available View source Failure of communication in coordinating family notification of death View source Failure of observation records to specify and capture who and when observations are completed View source Lack of detailed guidance on access to and type of ligature cutters View source Failure to provide essential patient and emergency-equipment information to external emergency services View source Failure to ensure immediately available ligature cutters in the secure clinic View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Darren Bartholomew · 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
Mark Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and make essential observation documentation available
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication in coordinating family notification of death
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of observation records to specify and capture who and when observations are completed
Wider context from the report “3. The Trust has a documented Observation Policy. Whilst the Policy requires records to be contemporaneously recorded, it does not specify how this is to be achieved . The actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed and in its present format would not withstand a rigorous audit .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed guidance on access to and type of ligature cutters
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic. The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later. To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide essential patient and emergency-equipment information to external emergency services
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate . More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediately available ligature cutters in the secure clinic
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic . The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later . To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” Open source report
Concerns raised 3 Inconsistent referral of unwell A&E attenders to a psychiatrist View source Lack of age-appropriate observation guidance for children and adolescents in specialist mental health units View source Lack of formal communication and information-transfer protocols between healthcare establishments 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
Miss Samiyo Sahra Shih Farah · 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
Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent referral of unwell A&E attenders to a psychiatrist
Wider context from the report “3) There appears to have been an inconsistency of approach following Miss Farah’s admissions to A & E. She was referred directly to a Psychiatrist on the second attendance when she was clearly unwell but had not managed to self-harm but was not on the first attendance when she had taken an overdose . This also raises the question as to whether she ought to have been referred (to a Psychiatrist) on the 31st October 2012 .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of age-appropriate observation guidance for children and adolescents in specialist mental health units
Wider context from the report “1) Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units . At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues . The care needs of young people are quite different to those of adults .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal communication and information-transfer protocols between healthcare establishments
Wider context from the report “2) Communication/contact between transferring establishments - there is no formal policy/protocol in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors , thus risking that not all key information (both verbal and written) is properly communicated before, during and after transfer . Whilst progress is being made in this regard at local level following the death of Miss Farah (and may well be the basis upon which any national policy/protocol might be formulated) there is currently no communication/transfer protocol in existence . This also potentially impacts upon all other healthcare sector providers e.g. the acute sector, hospital to care home, acute to rehabilitation/community services etc.
” Open source report
Concerns raised 4 Failure to appropriately record patients’ medical conditions and blood test readings in clinical notes View source Failure to apply an available defibrillator promptly during resuscitation View source Delays in obtaining patients’ previous diabetes medication regimes View source Failure to pass acceptable blood test result parameters to relevant clinical staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Walker · 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
Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately record patients’ medical conditions and blood test readings in clinical notes
Wider context from the report “(2) Information concerning Mrs Walker’s medical condition and blood test readings was not appropriately recorded in her clinical notes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply an available defibrillator promptly during resuscitation
Wider context from the report “(3) When Mrs Walker was found unresponsive at approximately 6.00am on the morning of the 7th August 2012, cardio-pulmonary resuscitation was appropriately commenced and continued and a defibrillator was obtained. However the defibrillator was not applied prior to the arrival of ambulance personnel who then applied their own defibrillator, which did not reveal a heart rhythm suitable for a shock to be given.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining patients’ previous diabetes medication regimes
Wider context from the report “(1) Following Mrs Walker’s admission to the Sephton Unit at Leigh Infirmary as a detained patient on 4th March 2012, details of her previous medication regime for her diabetes were not sought until the 6th August 2012 . When these details were obtained on the 6th August 2012, information concerning the medication was passed to relevant clinical staff but information concerning what blood test results were acceptable for her was not so passed.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pass acceptable blood test result parameters to relevant clinical staff
Wider context from the report “(1) Following Mrs Walker’s admission to the Sephton Unit at Leigh Infirmary as a detained patient on 4th March 2012, details of her previous medication regime for her diabetes were not sought until the 6th August 2012. When these details were obtained on the 6th August 2012, information concerning the medication was passed to relevant clinical staff but information concerning what blood test results were acceptable for her was not so passed .
” Open source report
Concerns raised 9 Failure to complete and record patient observations View source Lack of nurse review of recent records during admission or transfer handover View source Delays in admission to an appropriate mental health bed View source Failure to properly clerk in mental health patients View source Failure to implement handover policies in practice View source Lack of clinical supervision and guidance for junior medical staff View source Failure to conduct prompt, thorough and independent investigations of serious patient deaths View source Failure of junior medical staff to review clinical records and history before prescribing medication View source Lack of a reliable method for notifying the responsible Consultant of patient admission View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 13
Action
Inform trainees about the Rapid Tranquillisation protocol through induction and clarify consultants’ supervision responsibilities for junior-doctor prescribing.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source
Action
Adapt incident reporting to record Rapid Tranquillisation route and whether required physical and safe observations were maintained.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 December 2013. View source
Action
Review the SIRI policy to consider independent investigation of complex cases and identify a suitable investigation resource.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source
Action
Require contemporaneous, gap-free observation records, countersigning, physical handover, and staff accountability for completion.
Stated completedThe respondent said that this action was complete when they made their response on 13 December 2013. View source
Action
Instruct registered nurses to review recent admission records and risk information for unfamiliar patients, with understanding checked through supervision.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 December 2013. View source
Action
Provide weekly supervision for CT1–3 and ST4–6 trainees and reinforce its importance with trainees and consultants.
Stated completedThe respondent said that this action was complete when they made their response on 13 December 2013. View source
Action
Use admission-checklist sign-offs to confirm doctor clerking, physical examination, and consultant notification of hospital admissions.
Stated completedThe respondent said that this action was complete when they made their response on 13 December 2013. View source
Action
Carry out weekly checks of compliance with handover documentation requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source
Action
Review junior-doctor induction and consultant timetables to strengthen enforcement and documentation of clinical and educational supervision.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source
Action
Maintain the changed inpatient-bed access process, under which service users requiring admission do not have a waiting list.
Stated completedThe respondent said that this action was complete when they made their response on 13 December 2013. View source
Action
Audit compliance with admission clerking and consultant-notification requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source
Action
Develop guidance for SIRI investigators or chairs on learning from cases and defining investigation scope.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source
Action
Require nurse-in-charge end-of-shift review of observation records, correction and incident reporting of gaps, with Matron monitoring and policy-compliance audits.
Stated plannedThe respondent said that this action was planned when they made their response on 13 December 2013. View source See 10 more actions
×
AI-generated summary
STEPHANIE DANIELS · 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
Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.
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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and record patient observations
Wider context from the report “8. Performing and recording observations on other patients
I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nurse review of recent records during admission or transfer handover
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records . MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in admission to an appropriate mental health bed
Wider context from the report “3. Bed Availability
MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As I understood the evidence from the CCG in the case this should have occurred in any event. However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that they are not having the appropriate nursing and clinical input, as well as medication review . In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be. I am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly clerk in mental health patients
Wider context from the report “4. Clerking In
The failure to properly clerk in the patient is a matter of serious concern , especially as many such patients will have physical health problems. MHSC had clear policies requiring the clerking in of a patient, but these were simply not adhered to . It is very common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment. It seems that despite the existence of appropriate policies, in practice these were not being complied with . Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. I repeat what I have said earlier. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement handover policies in practice
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice . Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective .
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical supervision and guidance for junior medical staff
Wider context from the report “5. Supervision of Junior Medical Staff
I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff . Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prompt, thorough and independent investigations of serious patient deaths
Wider context from the report “1. Internal NHS SUI Investigation v Independent Investigation
I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin).
In this case there were significant errors and omissions in the SUI investigation . Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March.
This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced . This is a policy decision for the NHS but I strongly urge consideration of this.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of junior medical staff to review clinical records and history before prescribing medication
Wider context from the report “6. Prescribing of Medication by Junior Medical Staff
I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function.
” 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 Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable method for notifying the responsible Consultant of patient admission
Wider context from the report “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission
It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem.
” 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 Inform trainees about the Rapid Tranquillisation protocol through induction and clarify consultants’ supervision responsibilities for junior-doctor prescribing.
Verbatim wording from the response “████████ Interim Medical Director, will ensure that all trainees will be informed about the Rapid Tranquillisation protocol through the induction process. In addition, consultants will be made aware of their responsibilities in respect of supervision of junior doctors prescribing. The Trust has amended the prescription card to ensure that Rapid Tranquillisation is clearly identifiable and not confused with PRN (as necessary) medication. The Trust incident reporting system is being adapted to record whether Rapid Tranquillisation was administered intramuscularly or orally and whether physical / safe observations were maintained in line with Trust policy. This is monitored through induction attendance records, pharmacy daily monitoring of prescriptions and Datix incident reporting.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 Adapt incident reporting to record Rapid Tranquillisation route and whether required physical and safe observations were maintained.
Verbatim wording from the response “████████ Interim Medical Director, will ensure that all trainees will be informed about the Rapid Tranquillisation protocol through the induction process. In addition, consultants will be made aware of their responsibilities in respect of supervision of junior doctors prescribing. The Trust has amended the prescription card to ensure that Rapid Tranquillisation is clearly identifiable and not confused with PRN (as necessary) medication. The Trust incident reporting system is being adapted to record whether Rapid Tranquillisation was administered intramuscularly or orally and whether physical / safe observations were maintained in line with Trust policy. This is monitored through induction attendance records, pharmacy daily monitoring of prescriptions and Datix incident reporting.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 SIRI policy to consider independent investigation of complex cases and identify a suitable investigation resource.
Verbatim wording from the response “Following the concerns raised in your report about the Serious Untoward Incident the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases. The Trust will also develop further guidance for investigators regarding the learning from this case. As part of the review, the Trust will look at identifying a resource to carry out such independent investigations.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 Require contemporaneous, gap-free observation records, countersigning, physical handover, and staff accountability for completion.
Verbatim wording from the response “I share your concern about incomplete observation forms and the Head of Nursing has instructed staff that observation record forms must be completed contemporaneously and without any gaps. In addition, the nurse in charge must review the observations records during and at the end of the shift and ensure any gaps are addressed and reported through the Datix incident reporting system. The Matrons will monitor the recording of observations and the Trust will audit the compliance with the Safe and Supportive Observation policy.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 Instruct registered nurses to review recent admission records and risk information for unfamiliar patients, with understanding checked through supervision.
Verbatim wording from the response “As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over. The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staff have received and understood the instruction, which will be monitored through management supervision.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide weekly supervision for CT1–3 and ST4–6 trainees and reinforce its importance with trainees and consultants.
Verbatim wording from the response “I appreciate you have also sent your Regulation 28 Report to the Deanery at Manchester University. From a Trust perspective, all trainees graded CT1-3 and StR 4-6 have weekly supervision. Trainees and Consultants have been reminded of the importance of this and a discussion has taken place with the Deanery. This will be additionally monitored through the annual handover and supervision survey data completed by junior medical staff.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 admission-checklist sign-offs to confirm doctor clerking, physical examination, and consultant notification of hospital admissions.
Verbatim wording from the response “The Trust acknowledges the importance of clerking in service users upon admission. In order to strengthen our processes the admission checklist requires the nurse to sign that they have contacted the doctor to clerk in a new service user, and an additional sign-off once the doctor has clerked the service user in. It also incorporates the action to inform the consultant by email of hospital admissions. This will be monitored through audits.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 Carry out weekly checks of compliance with handover documentation requirements.
Verbatim wording from the response “As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over. The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staff have received and understood the instruction, which will be monitored through management supervision.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 junior-doctor induction and consultant timetables to strengthen enforcement and documentation of clinical and educational supervision.
Verbatim wording from the response “All trainees in the grades CT1–3 and ST4–6 have weekly supervision. Trainees and consultants have been reminded of the importance of this, and supervision will take place with the deanery on this. Supervision will be enforced at all times and the juniors’ induction and seniors’ timetables will be reviewed.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the changed inpatient-bed access process, under which service users requiring admission do not have a waiting list.
Verbatim wording from the response “I understand that you have raised this concern in your Regulation 28 Report as a national issue. However, as you are aware, following ████████ evidence at the inquest, this Trust implemented a change to how inpatient beds are accessed in January 2013 and we do not have a waiting list of service users requiring admission.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with admission clerking and consultant-notification requirements.
Verbatim wording from the response “The Trust acknowledges the importance of clerking in service users upon admission. In order to strengthen our processes the admission checklist requires the nurse to sign that they have contacted the doctor to clerk in a new service user, and an additional sign-off once the doctor has clerked the service user in. It also incorporates the action to inform the consultant by email of hospital admissions. This will be monitored through audits.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidance for SIRI investigators or chairs on learning from cases and defining investigation scope.
Verbatim wording from the response “Following the concerns raised in your report about the Serious Untoward Incident the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases. The Trust will also develop further guidance for investigators regarding the learning from this case. As part of the review, the Trust will look at identifying a resource to carry out such independent investigations.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
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 Require nurse-in-charge end-of-shift review of observation records, correction and incident reporting of gaps, with Matron monitoring and policy-compliance audits.
Verbatim wording from the response “I share your concern about incomplete observation forms and the Head of Nursing has instructed staff that observation record forms must be completed contemporaneously and without any gaps. In addition, the nurse in charge must review the observations records during and at the end of the shift and ensure any gaps are addressed and reported through the Datix incident reporting system. The Matrons will monitor the recording of observations and the Trust will audit the compliance with the Safe and Supportive Observation policy.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that inpatient bed availability creates a local waiting-list risk, stating that its revised access arrangements left no service users awaiting admission.
Verbatim wording from the response “I understand that you have raised this concern in your Regulation 28 Report as a national issue. However, as you are aware, following ████████ evidence at the inquest, this Trust implemented a change to how inpatient beds are accessed in January 2013 and we do not have a waiting list of service users requiring admission.” Source location 2013-0353-Response-by-Manchester-Mental-Health-NHS
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations