5 Jun 2017 David Ian Hamilton · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Failure to document or record therapy selection options and rationale View source Lack of clarity of triggers for referrals other than group therapy View source Failure to make referrals to sleep clinic services for insomnia View source Lack of a clear formal escalation process for concerns held by health professionals View source Limited information sharing between health professionals to identify service access and need for psychiatric referral View source See 2 more concerns
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. 3
Action
Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.
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Action
Escalated the lack of local insomnia sleep-clinic provision and referral support to the Tameside and Glossop CCG mental health lead.
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Action
Escalated concerns about inadequate mental health support for GPs to the Tameside CCG mental health leads.
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AI-generated summary
David Ian 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
David Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to document or record therapy selection options and rationale
Wider context from the report “1. Healthy Minds had no documentation or system of recording the selection process for therapy including the options given and rationale for the choice of therapy ;
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity of triggers for referrals other than group therapy
Wider context from the report “2. There was a lack of clarity of triggers for referrals other than group therapy ;
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to make referrals to sleep clinic services for insomnia
Wider context from the report “4. Referrals were not made to sleep clinic services to assist with insomnia
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear formal escalation process for concerns held by health professionals
Wider context from the report “5. There was no evidence of a clear formal escalation process where concerns were held by a health professional
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Limited information sharing between health professionals to identify service access and need for psychiatric referral
Wider context from the report “3. The system of sharing information between health professionals (the GP and Healthy Minds) to identify if the correct services were being accessed or if a referral to a psychiatrist was required was limited and meant that those involved did not have a full picture of his mental health;
” 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 Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.
Verbatim wording from the response “3) We have also written to the Mental Health Lead to ask for improved communication between the Healthy Minds and the GPs.” Source location 2017-0180-Response-by-Grosvenor-Medical-Centre
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 Escalated the lack of local insomnia sleep-clinic provision and referral support to the Tameside and Glossop CCG mental health lead.
Verbatim wording from the response “Based on the information that the RAID team is advising patients to ask for sleep clinic referrals and their letter to us advising us to refer, we have since found out that there is no sleep clinic for insomnia within Manchester.
The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is 20 days.
There is no other therapy being offered within Manchester for Insomnia. It would therefore be helpful in informing the RAID team of the lack of this service within Manchester area, if they are already not aware, so that patients can be guided appropriately by them.” Source location 2017-0180-Response-by-Grosvenor-Medical-Centre
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 Escalated concerns about inadequate mental health support for GPs to the Tameside CCG mental health leads.
Verbatim wording from the response “I attended the inquest on 01-06-17 and it is very helpful to have your report. I have since, fed back to my colleagues in the practice and also raised concerns about mental health support with colleagues in the Clinical Commissioning Group. Your report has also been read by all my colleagues. We have tried to address the concerns. The actions taken are as below:” Source location 2017-0180-Response-by-Grosvenor-Medical-Centre
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 Local insomnia sleep-clinic provision is unavailable, so referrals require distant services with substantial waiting times.
Verbatim wording from the response “Based on the information that the RAID team is advising patients to ask for sleep clinic referrals and their letter to us advising us to refer, we have since found out that there is no sleep clinic for insomnia within Manchester.
The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is 20 days.
There is no other therapy being offered within Manchester for Insomnia. It would therefore be helpful in informing the RAID team of the lack of this service within Manchester area, if they are already not aware, so that patients can be guided appropriately by them.” Source location 2017-0180-Response-by-Grosvenor-Medical-Centre
Open published response
8 Dec 2016 Rachal Marie Murphy · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to undertake annual liver function tests View source Failure to review CAF documentation View source Lack of clarity about referral routes and acceptance by Psychological services View source Delays in reporting EEGs View source Delays in allocation of cases within Early Help Services View source Lack of understanding of cases suitable for CAMHS referral View source Lack of GP involvement in inter-agency case handling View source See 4 more concerns
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. 3
Action
Implement annual liver-function monitoring for patients prescribed sodium valproate, with due-date alerts, prescription checks and escalation of missed tests.
View source
Action
Route incoming CAF documents to the duty doctor for same-day action assessment, then scan and circulate them to regular GPs when no same-day response is required.
View source
Action
Search current sodium-valproate patients’ records and invite those overdue for liver-function testing to attend for blood tests.
View source
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AI-generated summary
Rachal Marie Murphy · 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
Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.
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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake annual liver function tests
Wider context from the report “1. There was a failure to undertake annual liver function tests in 2014 and 2015
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to review CAF documentation
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about referral routes and acceptance by Psychological services
Wider context from the report “1. There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals .
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting EEGs
Wider context from the report “3. There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest .
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Delays in allocation of cases within Early Help Services
Wider context from the report “1. The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved .
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of cases suitable for CAMHS referral
Wider context from the report “2. Lack of understanding amongst medical professionals as to the cases which may or may not be suitable for referral to CAMHS .
” 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 Grosvenor Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of GP involvement in inter-agency case handling
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement annual liver-function monitoring for patients prescribed sodium valproate, with due-date alerts, prescription checks and escalation of missed tests.
Verbatim wording from the response “1. The British National Formulary issue 72 advises that LFTs “should be checked before sodium valproate therapy is commenced and during the first 6 months of treatment, especially in patients most at risk”. Although the BNF does not advise checking LFTs annually for patients on sodium valproate, we all accept this would be good practice in view of the risk of hepatic dysfunction and have agreed to adopt this policy within the Practice.” Source location 2016-0401-Response-by-Grosvenor-Medical-Centre
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 Route incoming CAF documents to the duty doctor for same-day action assessment, then scan and circulate them to regular GPs when no same-day response is required.
Verbatim wording from the response “CAF documents received through the post will now be given to the duty doctor on the day they arrive, to determine whether any action is required that day, such as responding to CAF meeting invitations, liaising with any other colleagues involved in the patient’s care or arranging any follow up required at the Practice. Should no same-day response be needed, the document is then scanned and sent to all regular GP’s at the practice to read, in order that they are all made aware of the information contained.” Source location 2016-0401-Response-by-Grosvenor-Medical-Centre
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 Search current sodium-valproate patients’ records and invite those overdue for liver-function testing to attend for blood tests.
Verbatim wording from the response “I have done a search of the Practice list for all patients currently prescribed sodium valproate and noted when their last LFTs were checked. If this has not been within the last year, they have been sent a letter inviting them in for a blood test.” Source location 2016-0401-Response-by-Grosvenor-Medical-Centre
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations