Concerns raised 1 Failure to routinely inform OPMH of patients’ emergency department admissions and discharges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ethel Mitchell ROBERTSON · 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
Ethel Mitchell ROBERTSON, who had a long history of depression and anxiety, chronic alcohol consumption and previous intentional drug overdoses, was found deceased at home on 18 February 2024. The inquest concluded that she died from the consequences of an intentional overdose taken to end her life. The report raised concerns that the Older Persons Mental Health Service was not routinely informed when its patients attended or were discharged from an emergency department for physical-health issues, potentially delaying follow-up, risk management and decision-making.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely inform OPMH of patients’ emergency department admissions and discharges
Wider context from the report “An Area Matron at the Older People’s Mental Health Service [OPMH] gave evidence that the service is not routinely informed when one of their patients is admitted to or discharged from ED . If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital. However, if the presentation is for something not related to mental health, the OPMH will not be notified as clinicians within the ED do not have access to the computer systems operated by service providers in the community .
I am concerned that OPMH will not know if one of their patients has had a physical health crisis which could precipitate a decline in their mental health or has presented with something that those not familiar with the patient might fail to appreciate is linked to their mental health. I am concerned that this will have serious implications for patient safety and could delay appropriate follow-up, risk management and decision-making . It also places an added pressure on those in primary care to have systems in place to alert the community teams when they receive discharge documentation from ED.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Checking every Emergency Department patient for undisclosed mental illness is impractical and disproportionate because of workload, limited clinical indicators and privacy objections.
Verbatim wording from the response “However, to check every patient attending the Emergency Departments for physical health conditions as to whether or not they also have a mental illness is not practical. Some people with mental illness also have objections to their mental health records being shared more widely. Even with connected computer systems, the additional workload of checking every patient to establish whether they have mental health issues is disproportionate to the small number of cases where the mental health conditions are not evident to the clinicians in the Emergency Department.” Source location Response from Southern Health Foundation Trust
Open published response
Concerns raised 7 Linear approach to mental health risk assessment and formulation View source Non-patient-centred decision making in trust services View source Structural leadership issues within mental health trust services View source Unavailability of urgent visits by the specialist perinatal team View source Failure to escalate deteriorating patients View source Lack of mandatory perinatal red-flag training for community mental health teams View source Failure to demonstrate professional curiosity and obtain relevant information from family members View source See 4 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
Abigail Eleanor Ann Jelly · 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
Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and risk assessment.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Linear approach to mental health risk assessment and formulation
Wider context from the report “It was accepted that there were cultural issues within the trust services. A report into Abigail’s death concluded that these included ‘a lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation .’ I am concerned that there are structural issues with the leadership of the Hampshire and Isle of Wight Healthcare Trust that is to the detriment of patients like Abigail, and I am concerned about the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Non-patient-centred decision making in trust services
Wider context from the report “It was accepted that there were cultural issues within the trust services. A report into Abigail’s death concluded that these included ‘a lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation.’ I am concerned that there are structural issues with the leadership of the Hampshire and Isle of Wight Healthcare Trust that is to the detriment of patients like Abigail, and I am concerned about the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Structural leadership issues within mental health trust services
Wider context from the report “It was accepted that there were cultural issues within the trust services . A report into Abigail’s death concluded that these included ‘a lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation.’ I am concerned that there are structural issues with the leadership of the Hampshire and Isle of Wight Healthcare Trust that is to the detriment of patients like Abigail , and I am concerned about the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of urgent visits by the specialist perinatal team
Wider context from the report “The Perinatal Team are expert in assisting patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the community mental health teams who lack the specialist training and who are likely, due to the reasons outlined above, unaware of the perinatal red flags. I am concerned that women in need will not receive the appropriate mental health care and that there is a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate deteriorating patients
Wider context from the report “It was accepted that there were cultural issues within the trust services. A report into Abigail’s death concluded that these included ‘a lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation.’ I am concerned that there are structural issues with the leadership of the Hampshire and Isle of Wight Healthcare Trust that is to the detriment of patients like Abigail, and I am concerned about the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory perinatal red-flag training for community mental health teams
Wider context from the report “Community Mental Health Teams do not receive mandatory training on the perinatal red flags that are used when assessing patients with postnatal mental health issues. The team concerned with Abigail did request training but, a year after Abigail’s death, they had not received it. They were told that an assessment had been made by those senior to them that such training is not mandatory . That women suffer poor mental health before and after giving birth is sadly common and I am concerned that there is a risk of future deaths and that a large and vulnerable group of patients will not receive appropriate care.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate professional curiosity and obtain relevant information from family members
Wider context from the report “Abigail was known to the community mental health services for just a few weeks. She had been living with her parents immediately before she died and they had attended medical appointments with her. Abigail’s parents were not spoken to by mental health professionals about their daughter’s circumstances when they would have been able to provide valuable information about her research into and planning around ending her life. It was accepted that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally and I am concerned that there is a risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support teams to implement a comprehensive Quality Improvement Plan addressing structural care issues.
Verbatim wording from the response “Multidisciplinary team (MDT) “huddle” meetings are now established and provide a forum for clinicians to discuss referrals and caseloads. There are also weekly MDT reviews, in which Band 7 team leaders are more directly supporting staff in their focus on urgent face-to-face assessments. Additionally, more senior clinical leadership involvement has also been provided, and the teams are being supported to implement a comprehensive Quality Improvement Plan. These measures are aimed at addressing the structural issues that you describe.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide increased senior clinical leadership involvement to support the teams.
Verbatim wording from the response “Multidisciplinary team (MDT) “huddle” meetings are now established and provide a forum for clinicians to discuss referrals and caseloads. There are also weekly MDT reviews, in which Band 7 team leaders are more directly supporting staff in their focus on urgent face-to-face assessments. Additionally, more senior clinical leadership involvement has also been provided, and the teams are being supported to implement a comprehensive Quality Improvement Plan. These measures are aimed at addressing the structural issues that you describe.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with involved teams to improve professional curiosity when caring for patients.
Verbatim wording from the response “There was also a lack of professional curiosity in working with Abigail, and this has been worked on with the teams involved.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out a redesigned mental-health risk assessment and management training programme incorporating perinatal risks.
Verbatim wording from the response “The “Perinatal Red Flags” is information that is primarily targeted towards non-mental health professionals. It is not mandatory training for Mental Health Registrants, for whom it will have been an integral part of their core education in becoming a qualified mental health practitioner. What we are doing, however, is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Perinatal Red Flags training need not be mandatory for Mental Health Registrants because the content is covered in their core education.
Verbatim wording from the response “The “Perinatal Red Flags” is information that is primarily targeted towards non-mental health professionals. It is not mandatory training for Mental Health Registrants, for whom it will have been an integral part of their core education in becoming a qualified mental health practitioner. What we are doing, however, is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme.” Source location Response from Hampshire and Isle of Wight Healthcare
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 Perinatal Team is not commissioned to complete urgent visits and must refer patients to Community Mental Health Teams.
Verbatim wording from the response “As you state, the Perinatal Team are expert in assessing patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the Community Mental Health Teams. This is an arrangement that is common in most parts of the country. The important issue is the drawing on specialist perinatal expertise when needed, through very close working between the Crisis Resolution Home Treatment Teams (CRHTs) and the specialist Perinatal Team.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
Concerns raised 6 Failure to identify non-compliance with risk assessment policy through auditing View source Failure to provide face-to-face care-coordinator appointments View source Inadequate training on risk assessments View source Failure to refer or transfer care to the geographically appropriate community mental health team View source Failure to maintain family involvement in care during telephone care-coordinator meetings View source Failure to complete formal risk assessments in accordance with policy 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
Naomi Aylott · 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
Naomi Aylott died on 12 September 2024 after jumping from a railway bridge with the intent to end her own life, following a period of poor mental health and previous suicide attempts. Concerns included that she was not seen face to face by her care co-ordinator, formal risk assessments and care planning were not completed, risk-assessment training and auditing were inadequate, and family involvement during telephone-based care had not been properly considered.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify non-compliance with risk assessment policy through auditing
Wider context from the report “2. I am concerned that within the Andover CMHT the training around risk assessments and the auditing of compliance with risk assessment policy is not adequate.
In relation to Naomi I heard evidence that the completion of formal risk assessments was not carried out in accordance with the CMHT policy.
I heard evidence that Andover CMHT had undergone risk assessment training at around the time they were involved in Naomi’s care. Despite this no formal risk assessments were completed. In addition I heard that the process for auditing risk assessment compliance had not identified this failure in respect of Naomi’s care.
I also heard evidence that the Andover CMHT had requested further training from the Hampshire and Isle of Wight Trust but that this had not 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face care-coordinator appointments
Wider context from the report “1. I am concerned that Naomi was never seen face to face by her care co-ordinator over the 3 – 4 month period that she was under the care of the CMHT.
I heard evidence that the Andover CMHT, in particular, was impacted by a change in the way that primary care networks (PCNs) refer patients to secondary services. Due to Naomi’s GP surgery being within a particular PCN she was referred to the Andover CMHT even though she lived in Four Marks, a 40-50 minute drive from Andover. This is much further than would have been the case had Naomi come under the care of the Winchester CMHT.
The Andover CMHT has not been able to arrange as many face to face appointments with care co-ordinators due to the time they would have to spend travelling .
Naomi’s care was not referred to the Winchester CMHT originally nor was it transferred from the Andover to the Winchester CMHT after the referral was accepted.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training on risk assessments
Wider context from the report “2. I am concerned that within the Andover CMHT the training around risk assessments and the auditing of compliance with risk assessment policy is not adequate .
In relation to Naomi I heard evidence that the completion of formal risk assessments was not carried out in accordance with the CMHT policy.
I heard evidence that Andover CMHT had undergone risk assessment training at around the time they were involved in Naomi’s care. Despite this no formal risk assessments were completed. In addition I heard that the process for auditing risk assessment compliance had not identified this failure in respect of Naomi’s care.
I also heard evidence that the Andover CMHT had requested further training from the Hampshire and Isle of Wight Trust but that this had not 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer or transfer care to the geographically appropriate community mental health team
Wider context from the report “1. I am concerned that Naomi was never seen face to face by her care co-ordinator over the 3 – 4 month period that she was under the care of the CMHT.
I heard evidence that the Andover CMHT, in particular, was impacted by a change in the way that primary care networks (PCNs) refer patients to secondary services. Due to Naomi’s GP surgery being within a particular PCN she was referred to the Andover CMHT even though she lived in Four Marks, a 40-50 minute drive from Andover. This is much further than would have been the case had Naomi come under the care of the Winchester CMHT.
The Andover CMHT has not been able to arrange as many face to face appointments with care co-ordinators due to the time they would have to spend travelling.
Naomi’s care was not referred to the Winchester CMHT originally nor was it transferred from the Andover to the Winchester CMHT after the referral was accepted .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain family involvement in care during telephone care-coordinator meetings
Wider context from the report “3. I am concerned that the Andover CMHT do not appear to have considered how to keep a person’s family involved in their care (when there is the appropriate consent to do so) when meetings with the care co-ordinator take place over the phone and not face to face .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete formal risk assessments in accordance with policy
Wider context from the report “2. I am concerned that within the Andover CMHT the training around risk assessments and the auditing of compliance with risk assessment policy is not adequate.
In relation to Naomi I heard evidence that the completion of formal risk assessments was not carried out in accordance with the CMHT policy .
I heard evidence that Andover CMHT had undergone risk assessment training at around the time they were involved in Naomi’s care. Despite this no formal risk assessments were completed . In addition I heard that the process for auditing risk assessment compliance had not identified this failure in respect of Naomi’s care.
I also heard evidence that the Andover CMHT had requested further training from the Hampshire and Isle of Wight Trust but that this had not taken place.
” 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 Carer Information Plans across services in the RiO electronic patient record, including consent and carer-support information.
Verbatim wording from the response “Our new Carer Information Plan officially launched in May 2025, and is available for all services, replacing the previous Carer Communication Plan. Carers were involved in the development of our new plans and the response has been overwhelmingly positive.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the standardised risk-management training programme using a train-the-trainers approach followed by full staff delivery.
Verbatim wording from the response “To ensure that they are as confident as possible in this field, a formal programme of risk management training has recently been developed for staff working in mental health services. This will standardise the offering across the organisation and will act as a refresher for staff. The roll out will commence in quarter 4 of 2025/26 with a ‘train the trainers’ approach, followed by a full programme of training delivery starting in quarter 1 of 2026/27.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish ESTHER Improvement Coaches and a staff ambassador network supporting person-centred care and family involvement.
Verbatim wording from the response “The introduction of ESTHER coaching has further enhanced and reinforced the Triangle of Care principles. ESTHER Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous improvement to ensure person-centred care. User involvement is integral to the model, building a network around the patient including family, friends, and key staff. Currently we have in excess of 90 staff members as ambassadors.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised organisation-wide mental-health risk-management training programme.
Verbatim wording from the response “To ensure that they are as confident as possible in this field, a formal programme of risk management training has recently been developed for staff working in mental health services. This will standardise the offering across the organisation and will act as a refresher for staff. The roll out will commence in quarter 4 of 2025/26 with a ‘train the trainers’ approach, followed by a full programme of training delivery starting in quarter 1 of 2026/27.” Source location Response from Hampshire and Isle of Wight Healthcare
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 Standardise community mental health risk-assessment compliance auditing through a revised Quality Assurance Tool.
Verbatim wording from the response “Routine audit of compliance has also been standardised across our organisation’s community mental health teams with the introduction of a revised Quality Assurance Tool in November 2025, which has been designed to specifically target the quality of risk assessments being completed. This is a Trust-wide approach and is much more sensitive to identifying shortfalls across our Mental Health Services and allowing remedial action to be taken.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke risk-management training sessions to community mental health teams, including Andover.
Verbatim wording from the response “Pending the roll out of our new risk management training programme, community mental health teams (including Andover) have received bespoke risk management training sessions delivered on a team-by-team basis at their local team base.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redirect rural patients to Winchester-based community mental health staff through new locality working arrangements.
Verbatim wording from the response “The Andover CMHT in particular, does cover a large geographical area and we recognise that this poses a logistical challenge for patients to be seen face to face. This has arisen as a result of the catchment area being defined by the externally allocated Primary Care Networks. We accept that this is not ideal and are actively taking steps to address this so that patients living in more rural parts of the area, as Naomi was, can instead be seen by staff based at a Winchester clinic. I expect these new ways of working to be fully implemented by January 2026.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Triangle of Care framework and updated co-produced training to Isle of Wight and legacy Solent staff.
Verbatim wording from the response “The Triangle of Care is an initiative promoted by the NHS, developed by the Carers Trust, to foster a therapeutic alliance between the service user, their family or carers, and the professional staff involved in their care. It emphasizes partnership, communication, and shared responsibility to promote safety, support recovery, and sustain the wellbeing of both the service user and their carer. Having rolled out the programme to legacy Southern Health staff over a number of years, we are now introducing the Triangle of Care framework to our staff in Isle of Wight and legacy Solent teams (who merged with Southern Health last year to become Hampshire and Isle of Wight Healthcare). Much of this training is co-delivered with carers, carers leads and a former service user with their carer. The training has recently been updated in coproduction with carers.” Source location Response from Hampshire and Isle of Wight Healthcare
Open published response
Concerns raised 3 Failure to incorporate family and friends' concerns into onward treatment and clinical assessment View source Failure to effectively communicate with and listen to families and friends of mental health patients View source Lack of risk-assessment training for agency staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samantha Kate YOUNG · 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
Samantha Young died at home on 20 November 2023 after intentionally taking her own life by hanging. She had a history of mental health difficulties, previous suicide attempts, and worsening condition amid significant stress. The concerns included insufficient training for agency staff in risk assessments and inadequate contact and communication with patients’ families and friends.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate family and friends' concerns into onward treatment and clinical assessment
Wider context from the report “B. Wider family and friends of the deceased perspective were not contacted.. A patient's family and friends are clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions ." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust similarly reported on shortfall in communication with families.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively communicate with and listen to families and friends of mental health patients
Wider context from the report “B. Wider family and friends of the deceased perspective were not contacted.. A patient's family and friends are clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved . Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns , based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust similarly reported on shortfall in communication with families.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of risk-assessment training for agency staff
Wider context from the report “A. Assessment of the risk that a patient poses to themselves or others is clearly a cornerstone of the work of an NHS Trust dealing with mental health. At the material time there was a lack of any training as to compilation of risk assessments . I was informed by a senior manager of Hampshire and Isle of Wight Healthcare NHS Trust that with the translation of Southern Health NHS Foundation Trust into the new Hampshire and Isle of Wight Healthcare NHS Foundation Trust that issue of training is being addressed. However it emerged at the inquest that there do not appear to be any firm plans to train agency staff . Agency staff form a significant percentage of frontline staff .
” 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 Introduce the Triangle of Care framework and updated co-produced training across Isle of Wight and legacy Solent teams.
Verbatim wording from the response “support recovery, and sustain the wellbeing of both the service user and their carer. Having rolled out the programme to legacy Southern Health staff over a number of years, we are now introducing the Triangle of Care framework to our staff in Isle of Wight and Legacy Solent teams (who merged with Southern Health last year to become Hampshire and Isle of Wight Healthcare). Much of this training is co-delivered with carers, carers leads and a former service user with their carer. The training has recently been updated in coproduction with carers.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an organisation-wide ESTHER ambassador network and provide ESTHER coaching courses.
Verbatim wording from the response “The introduction of Esther coaching has further enhanced and reinforced the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous improvement to ensure person-centred care. User involvement is integral to the model, building a network around the patient including family, friends, and key staff.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke risk-management training to community mental-health teams, open to substantive and agency staff.
Verbatim wording from the response “Pending the roll out of our new risk management training programme for our staff, community mental health teams are now receiving bespoke risk management training sessions delivered on a team-by-team basis at their local base. These sessions are open to both agency and substantive staff.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remedy missing carer data by capturing it on the data-insights visualisation platform.
Verbatim wording from the response “The audit report goes on to find: ‘The control effectiveness is Moderate as the Trust has been monitoring the Carers Plan and improvement initiatives properly with sufficient evidence available to prove their delivery progress. However, while the Trust uses OpenRio to record patient and carer information, it does not currently capture all essential data, which could limit its ability to monitor carers identification and support provided. Moreover, new roles and responsibilities of the Carers team are still being defined post-merger.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Carer Information Plan in the electronic patient record with consent, privacy and family-centred information fields.
Verbatim wording from the response “Our new Carer Information Plan officially launched in May 2025, and is available for all services, replacing the previous Carer Communication Plan. Carers were involved in the development of our new plans and the response has been overwhelmingly positive.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand carer feedback routes and fund or support carer groups, reporting feedback through governance groups.
Verbatim wording from the response “The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton and continue to fund an adult mental health carers group from diverse communities. Feedback and issues highlighted from these different platforms is reported to the services involved, the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting. As we develop our new Trust, an overarching Experience of Care group will be established and an unpaid carers group will report into the Experience of Care group.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree risk-management training materials with contracted agencies and require signposting before long-term community placements.
Verbatim wording from the response “Work is also underway to agree what training material can be shared with the agencies we contract with in order for them to signpost this to staff who are due to be starting on our longer-term placements. By way of an example, at the end of August 2025, NHS England released an e-learning programme called Staying Safe from Suicide. It is accessible for all staff including those working in the private or voluntary sectors. We intend to make this one of the training modules that the agencies we work with will need to signpost staff to prior to them accepting a community placement with us.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider additional pre-course risk-management material and pass any identified material to contracted agencies.
Verbatim wording from the response “In planning the delivery of our new risk management training programme we will also consider what other ‘pre-course’ material it would be useful for staff to have reviewed. Any additional material identified will be passed to agencies in the same way as above.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete an independent audit of arrangements for involving and listening to carers.
Verbatim wording from the response “In continuing recognition of the importance of carer engagement, the Trust last year commissioned an independent audit of this area. Specifically, the purpose of the audit was to review the adequacy of the Trust’s arrangements for involving and listening to carers in order that the Trust learns from their feedback and experiences. This was undertaken by our Internal Auditors—an external professional organisation specialising in governance and assurance. Their involvement reflects the seriousness with which the Trust approaches this issue.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask agencies to ensure transient agency staff have maintained risk-management competence.
Verbatim wording from the response “Whilst the above steps will ensure our long-term community agency staff are on a similar footing to Trust employees in respect of risk management training, the situation is admittedly more complex with our more transient agency workforce. These are staff who might have as little contact as attending a ward for a single shift with very short notice and who do not then work for the Trust again for several months. This staff group do not undertake the type of risk formulation and management that our longer-term community agency nurses do. We will be asking the agencies we work with to specifically ensure that these staff have maintained their competence in risk management but need to be upfront about the fact that logistically the other measures described above are not possible to take with this group.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out a standardised risk-management training programme across mental-health services, including access for long-term community agency staff.
Verbatim wording from the response “As was described in evidence at the inquest, a programme of risk management training is being developed for staff working in mental health services in order that this is standardised across our relatively new organisation. The finer details of the programme and practical elements such as mode and duration of delivery are being worked through, and the intention is to roll the programme out across the organisation in 2026.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Carers Champions in teams and honorary champions across the Trust.
Verbatim wording from the response “Carers Champions (Carers Leads)” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providing the full Trust training programme to all agency staff is not feasible because of logistical constraints, transience and additional cost.
Verbatim wording from the response “The position in respect of agency staff and training is a complex one. On the one hand, agency nurses are not our employees and often are a very transient part of the workforce. They are employed via their agencies and typically do not have access to the in-house training programmes of the various NHS Trusts they work at for a number of logistical and financial reasons.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agencies are responsible for ensuring agency nurses receive appropriate training, while registrants must maintain their own continuing professional development.
Verbatim wording from the response “By virtue of choosing to work via an agency, their access to training will typically not be through a single training department as would primarily be the case for staff employed by the NHS. Instead, whilst many agencies will provide access to statutory and mandatory training, it is the responsibility of the agency nurses to maintain their continuing professional development beyond this by accessing any additional training they may deem necessary. This can be from a multitude of different routes including accessing private training providers, freely available e-learning programmes or through professional journals, attending conferences/workshops etc. This onus on registrants to take responsibility for remaining competent in their area of practice is clearly set out in the Nursing and Midwifery Council’s Code of Conduct.” Source location Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Open published response
Concerns raised 2 Lack of an outside line on the seclusion-room observation handset for direct 999 emergency calls View source Failure to ensure that the ward's immediate access route is known and shared with emergency ambulance services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dean John Mark Anthony BRAY · 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
Dean Bray died of acute heart failure on 29 December 2021 while in the seclusion room on Hamtun Ward. The report identified failures to adequately monitor and escalate his high respiratory rate, and concerns about the ability to make emergency calls from the observation room and delays accessing the seclusion area.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an outside line on the seclusion-room observation handset for direct 999 emergency calls
Wider context from the report “Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that the ward's immediate access route is known and shared with emergency ambulance services
Wider context from the report “Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House.
” 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 Update emergency access information with South Central Ambulance Service annually or when additional inpatient units are added.
Verbatim wording from the response “In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services.” Source location Hampshire and IOW Healthcare 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 Agree a process with South Central Ambulance Service for updating emergency access information in its dispatch system.
Verbatim wording from the response “Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff.” Source location Hampshire and IOW Healthcare 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 Meet ambulance crews and escort them to the emergency location whenever they attend a Trust inpatient unit.
Verbatim wording from the response “In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services.” Source location Hampshire and IOW Healthcare 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 Adjust the Antelope House observation-room telephone line to enable external emergency calls.
Verbatim wording from the response “Immediately following the conclusion of the inquest, an adjustment was made to the internal phone line in the observation room in question at Antelope House, allowing external calls. In order to provide further assurance, we have also checked our other inpatient Mental Health units (where there are seclusion rooms) to ensure that they are unimpaired in being able to dial 999 in an emergency situation.” Source location Hampshire and IOW Healthcare 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 Check seclusion-room telephones across inpatient mental-health units to confirm they can dial 999.
Verbatim wording from the response “Immediately following the conclusion of the inquest, an adjustment was made to the internal phone line in the observation room in question at Antelope House, allowing external calls. In order to provide further assurance, we have also checked our other inpatient Mental Health units (where there are seclusion rooms) to ensure that they are unimpaired in being able to dial 999 in an emergency situation.” Source location Hampshire and IOW Healthcare 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 South Central Ambulance Service with emergency meeting locations for all Trust inpatient units.
Verbatim wording from the response “Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff.” Source location Hampshire and IOW Healthcare NHS
Open published response
Concerns raised 3 Failure of ED discharge summaries to clearly identify diagnoses and actions expected from GPs View source Failure of clozapine services to provide annual physical-health blood testing View source Failure to establish RCPath guidance for telephone escalation of raised triglyceride levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sebastian Harry 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
Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ED discharge summaries to clearly identify diagnoses and actions expected from GPs
Wider context from the report “2. The RCA report identified that the format of discharge summaries provided to GPs by the ED department needed to be reviewed to ensure that actions to be undertaken by GPs were clearly identified . The results of this were to be audited.
Following the inquest I was provided with an audit report. This report dated 13/9/21 revealed that the computer system could not be altered as had been hoped and therefore a change of practice was introduced instead. This required clinicians to document actions in a free text section with appropriate flagging for GPs. 20 cases were audited and only half met the standard national guidance and 8 lacked a clear diagnosis & details of what was expected from GPs .
Hampshire Hospital Trust have informed me that further actions are being taken to address these deficiencies. However as it is now a year since the RCA report was prepared and over 2 years since Mr Daniel’s death I am concerned that this action is not being taken swiftly given the risks to 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clozapine services to provide annual physical-health blood testing
Wider context from the report “3. In relation to the blood tests required under the clozapine guidelines I was informed that Southern Health take the monthly blood tests and run these in the clozapine clinic. However the blood tests required of the annual physical health checks are not taken by the Southern Health staff but rather patients are required to attend phlebotomy services elsewhere for the blood to be taken .
I heard evidence during the inquest that Mr Daniels had missed some of these blood test appointments which meant his full tests were not carried out when expected. Clozapine is prescribed only to patients suffering from an enduring mental health condition for whom other medication has not been effective which indicates that they may be at risk of having difficulty managing appointments.
I heard evidence from the consultant psychiatrist responsible for Mr Daniel’s treatment that they were not permitted to take the blood samples and submit them to the local laboratory for testing . I was informed that the Southern Health staff had requested to be able to do this to avoid the patient having to attend another appointment.
I have reviewed further information provided after the inquest by the Clinical Director of Southern Health. She has explained that they lack the facilities to complete the full blood tests and the lack the resources to take and deliver samples to the laboratories ; noting that no community mental health teams in their trust routinely provide phlebotomy services. She has advised that they are focussed on better communication with primary care and assertive outreach where necessary.
I remain concerned that patients on high risk medication, who by the nature of their mental health condition may struggle to attend appointments, are required to arrange or attend separate blood tests. I note that clozapine clinic staff also blood monthly and that the physical health reviews are carried out by doctors all of whom should be capable of taking a blood sample for submission to a laboratory.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish RCPath guidance for telephone escalation of raised triglyceride levels
Wider context from the report “1 The abnormal triglyceride levels in Mr Daniel’s blood, whilst reported by the lab, were not escalated by telephone as this was not required by the hospital procedure at the time.
I am pleased to note that Hampshire Hospitals Trust have updated their procedures to include telephone escalation of raised triglyceride levels.
However the RCA report indicated that the findings in this case should be shared with the Royal College of Pathologists with a request that raised triglyceride levels be added to the RCPath guidelines for telephone action . In information received after the inquest the Hampshire Hospitals Trust advised that they could not tell me whether or not this action has been undertaken .
” 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 Review variation in service provision across Clozapine clinics and use the findings to inform improvement.
Verbatim wording from the response “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.” Source location Response from Southern Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish consistent principles across Clozapine clinics for annual health-check capacity, preferred onsite blood sampling and robust results-review systems.
Verbatim wording from the response “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.” Source location Response from Southern Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operationalise blood sampling in Mid and North Hampshire Clozapine clinics using equipment, blood transport arrangements and a staff rota.
Verbatim wording from the response “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.” Source location Response from Southern Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop systems to identify required blood tests, record completed samples, optimise patient records and track results for Mid and North Hampshire Clozapine clinics.
Verbatim wording from the response “The Mid and North area have volunteered to operationalise this as an early adopter and since receipt of the Regulation 28 report have identified the equipment needed, made arrangements to have bloods transported to Andover War Memorial Hospital lab and have developed a rota of who would be able to take blood in each clinic. They are now working through how best to identify which patients need which bloods when, how to record when these have been taken and how to optimise or supplement current patient record systems to be able to track and follow up on results.” Source location Response from Southern Health NHS Foundation Trust
Open published response
Concerns raised 7 Failure to complete and store mental health unit handover records in SystmOne View source Lack of structured arrival handover and risk-history enquiry for detained patients View source Failure to securely store and share Queen Alexandra Hospital mental health records View source Failure to routinely flag patient risks in the Oceana records system View source Failure to properly record, store or audit paper observations and records View source Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements View source Lack of timely cross-local access to relevant electronic patient records View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack FARRINGTON · 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
Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and store mental health unit handover records in SystmOne
Wider context from the report “I heard evidence that the staff within the secure mental health unit rely very heavily on information given at handovers at the start of a shift and they do not have time to review the patient records in detail. At the time of Jack’s death records of these handovers were not stored in the same way as other patient records and, in Jack’s case, were missing entirely. This significantly hampered the investigation and inquest.
I am pleased to hear that Solent NHS Trust have now changed their document storage policy in this regard and these records will now be added to and stored on SystmOne.
However the handover records are not currently completed within SystmOne . This gives rise to the continuing risk of this information not being correctly recorded or correctly stored . I understand that this requires a change to SystmOne which is not yet 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured arrival handover and risk-history enquiry for detained patients
Wider context from the report “I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patients history of absconding or self harm . This gives rise to the possibility of a patient’s risk not being properly assessed .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to securely store and share Queen Alexandra Hospital mental health records
Wider context from the report “There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This significantly hampered the investigation and restricted the information available to the jury.
I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing records are now kept within an Enhanced Care Plan but this is still a paper format and therefore the risk of inadequate information sharing and failing to store records remain .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely flag patient risks in the Oceana records system
Wider context from the report “I heard in evidence that it is possible for patient risks to be ‘flagged’ within the Oceana records system to ensure that all staff are made aware of these. This was not done in Jack’s case and that this was not done as a matter of course , The Acting Medical Director was not aware of an established policy or procedure about using this existing functionality .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record, store or audit paper observations and records
Wider context from the report “Solent NHS Trust still relies on paper forms for some observations and record keeping within the mental health unit . In Jack’s case these were not scanned and stored which hampered the investigation and inquest. There remains a risk that where paper records are kept information is not properly recorded, stored or audited .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements
Wider context from the report “A ‘Mental Health Primary Disturbance Survey’ tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk based decisions that such guards were not necessary.
However I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding . The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely cross-local access to relevant electronic patient records
Wider context from the report “I heard evidence that there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information.
I also received evidence that the new NHS England National Record Locator system only acts as a flag to show who holds records rather than allowing access to clinicians .
This fragmentation of patient records means that medical and mental health practitioners do not have quick access to relevant information about their 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 Transfer inpatient handovers from Word documents to SystmOne and train staff in the new process.
Verbatim wording from the response “Work is continuing to transfer the handover from a Word document onto SystmOne. This was due to be completed by 01st October 2023, however due to changes in key staff members undertaking this change and the handover document provided on SystmOne that is in use in other clinical areas of Solent not being suitable for use in an acute psychiatric ward, there has been a delay to progress. Work is underway and expected to be completed, with staff trained in its use by the Clinical Practice Education Team by the end of January 2024. I am regretful that the service has not been able to deliver this change in handover process by the date previously proposed in my Witness Statement dated 09th August 2023. If HM Coroner would find it useful, I can provide a further update at the end of January when the SystmOne handover is live and in use.” Source location Response from Solent NHS 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 Work with Portsmouth Hospitals University NHS Trust and continue supporting developments addressing emergency-department handover and shared patient care arrangements.
Verbatim wording from the response “I hope that my letter has addressed the concerns raised from Mr Farrington’s inquest. I have noted that there were concerns addressed to both NHS England and Portsmouth Hospitals University NHS Trust in addition to Solent NHS Trust. I am pleased to report that our service has been working with Portsmouth Hospitals University NHS Trust to address the concern raised regarding handover on arrival at the Emergency Department and will continue to support Portsmouth Hospitals University NHS Trust in future developments and care arrangements for our shared patient groups.” Source location Response from Solent NHS 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 Attend inpatient handovers, audit clinical records, and escalate audit outcomes through governance meetings to assure handover quality and accuracy.
Verbatim wording from the response “In order to mitigate the risk that the continued use of the handover outside of SystmOne presents, our Clinical Leadership Team are attending handovers to ensure good quality conversation and accuracy of information handed over and undertaking a quality audit of the clinical records. The outcomes from audits are then presented at the Inpatient Governance Meeting and can be escalated to the Mental Health Service Senior Leadership Team at Integrated Governance Meeting if required.” Source location Response from Solent NHS 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 Replace paper-based clinical observation forms with electronic forms feeding directly into SystmOne, including tablet procurement and ward testing.
Verbatim wording from the response “The Mental Health Service continues to record various clinical observations on paper-based forms, which are scanned into SystmOne. This includes therapeutic engagement and observations, physical observations, food and fluid charts. The service is working towards replacing the paper-based forms with an electronic form that feeds directly into SystmOne, and I am pleased to report that work is on track and planned to be implemented by 01st April 2024. The Service’s Clinical Matron has visited departments within Southern Health NHS Foundation Trust to view the system in use and is meeting regularly with Solent NHS Trust Information Specialist to ensure this will be ready to implement on time. This change also involves the procurement of tablets to record the information on, which will be tested in all areas of the wards.” Source location Response from Solent NHS Trust
Open published response
Concerns raised 8 Unavailability of affordable NHS ADHD services View source Failure to communicate effectively with and listen meaningfully to families of patients with mental health difficulties View source Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway View source Fragmented connectivity between mental health and physical or neurodivergence services View source Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment View source Failure to brief families on neurodivergent and mental health diagnoses and their potential difficulties View source Failure to provide advice on possible medication withdrawal symptoms View source Lack of a comorbidity policy guiding staff caring for patients with mental health conditions and learning difficulties View source See 5 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. 16
Action
Roll out the Personality Disorder and Complex Trauma model through a steering board and six implementation workstreams.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Deliver whole-system trauma-informed training and cultural change across relevant organisations.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Implement the new Personality Disorder and Complex Trauma model through an approved phased plan.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Establish a single community and mental health provider through Project Fusion.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Develop the clinical psychology workforce through an apprenticeship scheme and 48 Clinical Associate in Psychology roles.
Stated completedThe respondent said that this action was complete when they made their response on 11 December 2023. View source
Action
Provide carer information and support through booklets, a public website and community-based Carers and Patient Support Hubs.
Stated completedThe respondent said that this action was complete when they made their response on 11 December 2023. View source
Action
Progress Triangle of Care accreditation from Star 2 toward Star 3.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Maintain three recruit-to-train posts and provide further training for existing staff delivering evidence-based interventions.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Develop inpatient tools supporting patients with Personality Disorder.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Deliver Triangle of Care training to staff and include it in Healthcare Support Worker induction.
Stated completedThe respondent said that this action was complete when they made their response on 11 December 2023. View source
Action
Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
Stated plannedThe respondent said that this action was planned when they made their response on 11 December 2023. View source
Action
Develop and run an expanded Family Connections programme for families of people with complex emotional needs, including neurodiversity.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023. View source
Action
Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
Stated completedThe respondent said that this action was complete when they made their response on 11 December 2023. View source
Action
Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
Stated completedThe respondent said that this action was complete when they made their response on 11 December 2023. View source
Action
Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
Stated completedThe respondent said that this action was complete when they made their response on 11 December 2023. View source See 13 more actions
×
AI-generated summary
Kirsty Clare TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of affordable NHS ADHD services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity. It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients.
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate effectively with and listen meaningfully to families of patients with mental health difficulties
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved . Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns , based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions.
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically, there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed. In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway
Wider context from the report “2. Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approach , which is both compassionate and recovery focused. It is evident that the 'Personality Disorder Pathway' currently being developed is an important step towards that aim, enabling practitioners and services to take a more holistic and person-centred approach, reducing risk and improving outcomes. I am aware that SHFT have been encouraged to review and further develop the Pathway. I am concerned that that must occur, and at pace .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented connectivity between mental health and physical or neurodivergence services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity . It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients .
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow . More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions .
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically , there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed . In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to brief families on neurodivergent and mental health diagnoses and their potential difficulties
Wider context from the report “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses . Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice on possible medication withdrawal symptoms
Wider context from the report “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses. Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a comorbidity policy guiding staff caring for patients with mental health conditions and learning difficulties
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity. It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients.
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty . There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths prevented.
” 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 Roll out the Personality Disorder and Complex Trauma model through a steering board and six implementation workstreams.
Verbatim wording from the response “A programme Steering board and 6 workstreams have formed to ensure a structured roll out and oversight of the implementation plans. One of the workstreams is the Families and Carers Support workstream and the Trust would again very much welcome Kirsty’s family to participate in this. ████████ will be in touch with them about this shortly as we recognise that their generous offer to give their time to support these changes will be invaluable.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver whole-system trauma-informed training and cultural change across relevant organisations.
Verbatim wording from the response “As part of embedding the trauma-informed approach¹ the Trust is involved in a whole system piece of work to ensure that wherever an individual or family touches our services they will experience a trauma-informed response. This is a large-scale piece of work involving training and cultural change across a range of organisations. Connected to this and as part of the NHS England Mental Health, Learning Disability and Autism Quality” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the new Personality Disorder and Complex Trauma model through an approved phased plan.
Verbatim wording from the response “In order to ensure that the Trust responded to this combination of local analysis and national and international developments, a new model has subsequently been developed over the past year for all services working with people who have Personality Disorder and Complex Trauma.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
Verbatim wording from the response “In addition to the training, we intend to build a network across the county to share best practice and tackle issues collectively and we have a number of working groups in place, which include broad input across clinical and corporate services and the service user voice, with a remit is to ensure what we have designed is measurable, tested and sustainable for the future.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a single community and mental health provider through Project Fusion.
Verbatim wording from the response “There is consensus that we will be more likely to achieve this future by joining up the disparate, often inconsistent services and pathways delivered by four different community and mental health providers. It has therefore been concluded that the best way to enable our vision is by working together to establish a new, single community and mental health provider, while, at the same time, accelerating collaboration and transformation, led by our clinical experts, to reduce the significant pressures in our system. The creation of this new provider is progressing at pace (Project Fusion) with the new legal entity due to be in place by 1 April 2024.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the clinical psychology workforce through an apprenticeship scheme and 48 Clinical Associate in Psychology roles.
Verbatim wording from the response “A separate measure taken to mitigate the national shortage of psychology staff has seen the Trust developing a new workforce and running an apprenticeship scheme with Plymouth University to develop Clinical Associates in Psychology (CAPS). Since 2022, the Trust has developed 48 CAPS across the organisation (3 cohorts of 16).” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide carer information and support through booklets, a public website and community-based Carers and Patient Support Hubs.
Verbatim wording from the response “Carer information is now readily available through booklets and also via a dedicated section of our public facing website. A new Carers and Patient Support Hub was also set up in January 2022 and this is a listening service available to family members/carers who need additional advice, information or support. In order to ensure that this service is accessible to all we have set up hubs in community settings as well as our clinical areas. For example, we have hubs in areas such as Totton, Romsey, Lymington, Southampton and one in development in the North of Hampshire.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress Triangle of Care accreditation from Star 2 toward Star 3.
Verbatim wording from the response “In June of this year we were delighted to be awarded Triangle of Care Star 2 accreditation and we are now working towards Star 3 to complete the process. In order for a mental health trust to achieve star 2 status, it must not only have completed the self-assessment for inpatient wards and crisis services, but also provision of support within community mental health services.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain three recruit-to-train posts and provide further training for existing staff delivering evidence-based interventions.
Verbatim wording from the response “As part of the new Personality Disorder and Complex Trauma model, the Trust is seeking to increase access for individuals to evidence-based interventions, aligning with the national agenda on increasing access for individuals with severe mental illness. Funding received for ‘recruit to train’ posts is enabling this to happen.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop inpatient tools supporting patients with Personality Disorder.
Verbatim wording from the response “A further workstream which is focussed on the in-patient pathway has as one of its strands the development of tools to support patients with a Personality Disorder should they be admitted to hospital. This group includes among its membership experts by experience with neurodiversity and the Trust fully recognises the need for the whole pathway to be accessible for this patient group.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Triangle of Care training to staff and include it in Healthcare Support Worker induction.
Verbatim wording from the response “We are delivering a ‘Triangle of Care’ training package (launched by the Carers Trust) to frontline staff with more than 2000 staff having completed this training since 2019. Much of this training is co-delivered with Carers, Carers Leads and a former service user with their carer. Triangle of Care training is ongoing and available weekly for all staff. 17 Carers Leads and 14 nurses/practice development nurses have been trained to facilitate the training package.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
Verbatim wording from the response “The introduction of Esther coaching this year will further enhance and reinforce the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and run an expanded Family Connections programme for families of people with complex emotional needs, including neurodiversity.
Verbatim wording from the response “Whilst we were initially only able to offer this in the Trust to a small sub-set of families whose relative was receiving a particular combination of interventions, we have sought to expand this. A new Family Connections model has been developed and has been run by Clinical Associates in Psychology (part of our new workforce expansion described in 2 above) for other family members with good outcomes.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
Verbatim wording from the response “Policies and protocols with regards to information sharing (including the issue of capacity) are also in place. The Trust promotes the importance of both the 7th and 8th principles of the UK Caldicott Guardian Council in recognising the importance of the duty to share information being as important as the duty to protect patient confidentiality. They are included with our Triangle of Care work and information governance (IG) training. IG training is completed annually by every member of staff which will help to embed these principles further.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
Verbatim wording from the response “The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton. Feedback and issues highlighted from these different platforms is reported to the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
Verbatim wording from the response “There are 152 carer leads in teams across the Trust with an additional 63 honorary Carers Leads – influencers and ambassadors. These are members of the team with a responsibility to champion family and carer engagement as part of their wider clinical role. We have also employed 22 staff in the roles of Carer Support Workers across the Trust. These are paid roles exclusively for working with carers.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delivery of the new Personality Disorder and Complex Trauma model must be phased to align with available commissioner funding.
Verbatim wording from the response “The delivery of this new model will be in a phased approach to align with available funding from commissioners with the first phase of work focussed on reducing waiting times for psychological therapy in secondary care.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing transformation work and developing Standard Operating Procedures are considered sufficient without a specific policy for comorbidities.
Verbatim wording from the response “These working groups are developing principles and Standard Operating Procedures for use across the new organisation when it comes into being.” Source location Response from Southern Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning neurodiversity services is outside the respondent’s control, so it is focusing on responsibilities within the new organisation.
Verbatim wording from the response “As we are not in control of the commissioning of these services and as commissioning changes may not be immediate, we are therefore focussing on what we are and will be responsible for in the new organisation and where we can lead by example. We know from” Source location Response from Southern Health NHS Foundation Trust
Open published response
Concerns raised 1 Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women 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
Sarah Jane Buckingham · 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
Sarah Jane Buckingham died by hanging at her home on 12 August 2019 after a period of depression and a recent voluntary admission to a mental health hospital. The principal concern was that hormonal treatment or hormonal changes associated with perimenopause were not considered by the mental health clinicians treating her depressive illness, despite relevant previous episodes following childbirth.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women
Wider context from the report “Sarah had been started on Hormone Replacement Therapy (HRT) by her GP in November 2017 as she was peri-menopausal. She began to experience and suffer from symptoms of depression once again in March 2019, and was clinically diagnosed with a depressive illness and anxiety.
It was only during a voluntary hospital admission between 28th – 30th July 2019 that Sarah had a blood test taken, which included a hormone profile. This was some four months into her illness and was only taken as 'routine'.
It transpired from the evidence at Sarah's Inquest that hormone treatment and/or hormonal triggers for depressive illness were not considered by the Mental Health Clinicians treating Sarah . I heard evidence that those treating Sarah relied on, and followed, NICE Guidelines but that NICE Guidance on Depression does not say anything about the routine monitoring of hormones, or that consideration be given to this potential contributory factor when treating menopausal or perimenopausal women . The significant impact of changing hormones was considered very early on in Sarah's treatment for PND, but was not considered at all during her last episode of depression ; with no justification or explanation as to why the impact of changing hormones was considered significant after birth, but not significant during menopause. I believe that an early consideration of these issues when treating a menopausal patient, and understanding of the potential interplay between hormonal changes and depression, may assist in formulating an effective treatment plan for patients such as Sarah.
” Open source report
Concerns raised 2 Insufficient liaison between involved practitioners about crisis support View source Lack of clarity about agency responsibility for immediate assistance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Daniel TWIDDY · 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
George Daniel TWIDDY was found hanging from a tree on 15 November 2017 and died in hospital on 17 November 2017 after suffering an untreatable brain injury. The principal concern was a lack of clarity between the Hampshire AMHP Service and Southern Health NHS Trust’s Early Intervention Psychosis Team about responsibility for providing immediate assistance, leaving his parents and practitioners unclear about where help would come from.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient liaison between involved practitioners about crisis support
Wider context from the report “At George's Inquest I heard evidence that there was a lack of clarity in the days leading up to his death as to which of the two agencies that had been involved in his care (Hampshire AMHP Service and Southern Health NHS Trust's Early Intervention Psychosis Team) were in a position to provide him with immediate assistance. His parents were confused as to where help would come from and practitioners from the two agencies were unclear as to where the responsibility lay. Although an improved explanatory leaflet for families about the responsibilities of the agencies is now in the course of being finalised and liaison to clarify respective roles has now taken place between senior managers of the agencies, it appears to me that a better understanding of those roles would be achieved if the practitioners actually involved in patient care themselves liaised more about what action and support should be made available to patients and relatives in crisis situations such as that faced by George and his family in the last days of his life.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about agency responsibility for immediate assistance
Wider context from the report “At George's Inquest I heard evidence that there was a lack of clarity in the days leading up to his death as to which of the two agencies that had been involved in his care (Hampshire AMHP Service and Southern Health NHS Trust's Early Intervention Psychosis Team) were in a position to provide him with immediate assistance . His parents were confused as to where help would come from and practitioners from the two agencies were unclear as to where the responsibility lay . Although an improved explanatory leaflet for families about the responsibilities of the agencies is now in the course of being finalised and liaison to clarify respective roles has now taken place between senior managers of the agencies, it appears to me that a better understanding of those roles would be achieved if the practitioners actually involved in patient care themselves liaised more about what action and support should be made available to patients and relatives in crisis situations such as that faced by George and his family in the last days of his life.
” 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 Develop and implement a joint Section 140 policy for frontline staff supporting people during Mental Health Act assessments.
Verbatim wording from the response “HCC and SHFT are committed to producing a s140 policy to ensure greater understanding for all frontline staff who have a role in supporting the person and their families, while undertaking a Mental Health Act assessment.” Source location 2019-0150-Response-by-Southern-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 integrated pathways through monthly strategic workshops to improve joint crisis support, admission and discharge planning.
Verbatim wording from the response “HCC and SHFT share an equal commitment to address the serious concerns raised by the Coroner. HCC & SHFT have reviewed the PFD report findings together to plan how both agencies can adopt a more collaborative & effective approach, to support people in crisis as a result of their mental distress including where the Mental Health Act assessment process takes place.” Source location 2019-0150-Response-by-Southern-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 Maintain collaborative AMHP and AMHT arrangements, including staff shadowing and AMHT availability during Mental Health Act assessments.
Verbatim wording from the response “3.1 Both agencies have agreed to embark on a programme of joint work to organise Acute Mental Health Team staff (AMHT/ SHFT) to accompany the AMHP (HCC) and the Doctors as the assessing team members, so they can agree a support plan if admission to hospital is not deemed to be necessary and to be available at the time of the Mental Health Act assessment as required.” Source location 2019-0150-Response-by-Southern-Health-NHS-Trust
Open published response
Concerns raised 9 Unclear implementation of information-sharing arrangements when patients withdraw family consent View source Insufficient staff training in implementing patient observation policies and prioritising vulnerable patients View source Insufficient staff training on implementing family information-sharing arrangements after consent withdrawal View source Unclear safeguarding requirements for vulnerable patients who are victims of crime View source Unclear applicability of patient observation policies to all in-patients View source Erroneous belief that informal patients cannot be detained when safety concerns arise View source Failure of ward nurses to use section 5(4) powers to prevent unsafe patient departure View source Unclear staff responsibility to report patient crimes to the police regardless of consent View source Insufficient training on Mental Health Act implementation for informal patients 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
Eleanor Valerie Fyfe BRABANT · 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
On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear implementation of information-sharing arrangements when patients withdraw family consent
Wider context from the report “5.4 It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented , and further training appears to be necessary.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in implementing patient observation policies and prioritising vulnerable patients
Wider context from the report “5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training on implementing family information-sharing arrangements after consent withdrawal
Wider context from the report “5.4 It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented, and further training appears to be necessary .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear safeguarding requirements for vulnerable patients who are victims of crime
Wider context from the report “5.2 Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as Eleanor Brabant and their responsibility to report those crimes to the police, whether or not the patient consented.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of patient observation policies to all in-patients
Wider context from the report “5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Erroneous belief that informal patients cannot be detained when safety concerns arise
Wider context from the report “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances . The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward nurses to use section 5(4) powers to prevent unsafe patient departure
Wider context from the report “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear staff responsibility to report patient crimes to the police regardless of consent
Wider context from the report “5.2 Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as Eleanor Brabant and their responsibility to report those crimes to the police, whether or not the patient consented .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training on Mental Health Act implementation for informal patients
Wider context from the report “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently .
” Open source report
18 May 2018 Henry James Heselton · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to share relevant recent mental health information between mental health teams and general practitioners View source Failure to record relevant mental health history in care plans View source Failure to make vital mental health history readily findable and extractable from electronic records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry James Heselton · 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
Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant recent mental health information between mental health teams and general practitioners
Wider context from the report “2. There was a lack of communication between the mental health teams and the general practitioner. The fact that contact had been made by ████████ with both the acute and community mental health team was not shared with his General Practitioner. This left her without relevant recent history to inform her clinical judgement when she was contacted by ████████ on the 7th September 2016.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant mental health history in care plans
Wider context from the report “1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make vital mental health history readily findable and extractable from electronic records
Wider context from the report “1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information was not easy to extract for professionals needing to find information about a patient in a crisis.
” 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 collaborative My Safety & Crisis Plans with regular completion and update prompts, including after significant risk changes.
Verbatim wording from the response “The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors; demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is a significant change in risk.” Source location 2018-0152-Response-by-Southern-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 staff to document risk information in the revised Risk Summary Section.
Verbatim wording from the response “The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors; demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen when there is a significant change in risk.” Source location 2018-0152-Response-by-Southern-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 Embed GP communication requirements in acute and community mental health team procedures, instruct managers, and monitor compliance after referral triage.
Verbatim wording from the response “To address the shortcomings in the care provided to Mr Heselton, these principles have been included in the review of the Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures, and the team managers instructed to ensure that staff are aware of the requirement to communicate with GPs after triaging referrals and to regularly monitor that it is occurring.” Source location 2018-0152-Response-by-Southern-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 GP access to mental health records.
Verbatim wording from the response “Electronic communication has being developed to allow access to CHIE (formerly the Hampshire Health Record) and GP summary patient records and is being developed to allow access for GPs to the mental health record. But this does not mean that communication described above will be superseded.” Source location 2018-0152-Response-by-Southern-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 and use a Community Care Plan page to make care plans and risk summaries readily identifiable.
Verbatim wording from the response “There has also been a review of the care planning process, and a Community Care Plan page developed (since January 2018), where all care plans are inserted so that they can be readily identified as well as the Risk summary.” Source location 2018-0152-Response-by-Southern-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 and redesign the RiO electronic patient record to make vital clinical information easier to find.
Verbatim wording from the response “It has been recognised, by the Trust, that our electronic patient record, RiO, supports the recording and sharing of vital clinical information, including risk, more effectively than the previous paper record system, including improved legibility, organisation, sharing and identification of key information. However the system has faults and limitations, and information can be difficult to find. It is therefore subject to ongoing review so that it can be redesigned in a way which supports clinical practice. The clinical workforce receives training and support to be able to use the system effectively.” Source location 2018-0152-Response-by-Southern-Health-NHS-Trust
Open published response
Concerns raised 3 Lack of communication between partner agencies View source Lack of co-operative working between early intervention in psychosis and substance misuse services View source Failure to obtain key worker input for root cause analysis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Grant David Burns · 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
Grant David Burns took an excess quantity of methadone, heroin and Alprazolam while alone at The Booth Centre between 20.05 on 22 July and 15.15 on 23 July 2016, and died from Morphine, Methadone and Alprazolam Toxicity. Concerns included a lack of co-operative working and communication between mental health, substance misuse and partner agencies, and an incomplete Root Cause Analysis report due to missing input from a key worker.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between partner agencies
Wider context from the report “There was a lack of communication between partner agencies
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of co-operative working between early intervention in psychosis and substance misuse services
Wider context from the report “The death was the subject of Root Cause Analysis report by Southern Health NHS Foundation Trust who provided the Early Intervention in Psychosis Service (EIPS) for the deceased, which found there was a lack of co-operative working between the EIPS and the Substance Misuse Service based at New Road Southampton provided by Solent NHS 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain key worker input for root cause analysis
Wider context from the report “The Southern Health report highlighted that their report was incomplete because there was no input from the key worker at New Road despite best efforts
” 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 Create a Joint Working Practice document setting communication, joint-working and escalation standards for Substance Misuse Services and Adult Mental Health.
Verbatim wording from the response “Finally the seventh action is with regard to the third issue of the lack of communication between partner agencies. The action is to create a bespoke Joint Working Practice document to outline the standards expected of staff in Substance Misuse Services and Adult Mental Health with regard to communication between organisations where patients are supported by both. These standards should cover, though are not limited to: Frequency of contact; Joint visits/meetings and escalation process. This action commenced on the 3rd of April and is due to end on the 18th of April 2017. The outcome of the action is to maintain consistent shared knowledge of patients’ risks and needs, and how these can be addressed. It is anticipated that there will then be a clear understanding by patients and carers regarding the involvement of different services, including their roles and functions.” Source location 2017-0048-Response-by-Solent-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 Implement a referral process that identifies mental health involvement, initiates cross-service contact and joint working, assigns responsibility, and escalates unanswered contacts.
Verbatim wording from the response “The second action concerns referrals which are screened in Substance Misuse Services. The Change Grow Live Manager with the Solent NHS Trust Clinical Manager will identify if there is any involvement from mental health services. If Adult Mental Health is involved, contact is to be made via telephone call/letter or email with the mental health treating team to make them aware that the Substance Misuse Services are also involved in the patient’s care. A meeting will then be arranged to start the joint working process. A named staff member will be identified to take responsibility for this action, which will usually be the Change Grow Live Care Co-Ordinator. Should there be no response from the mental health team following the substance misuse workers making contact, they will escalate this to their line manager to raise with the Area Manager – Southampton Mental Health Team Manager.” Source location 2017-0048-Response-by-Solent-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 Maintain a shared spreadsheet of clients receiving Adult Mental Health and Substance Misuse Services, with updates through joint and standing meeting agendas.
Verbatim wording from the response “After a full assessment, it has been found that in this incident there was a lack of co-operative working between Southern Health mental health services (Early Intervention in Psychosis Team) and Substance Misuse Services. After some discussion, the action now required is to compile a spread-sheet of those clients identified as being worked with by Adult Mental Health and Substance Misuse Services. This spread-sheet needs to be updated at the Southampton Drug and Alcohol Recovery Service Management meeting with regular communication with Southern Health Foundation Trust. This action was put in place on the 27th of March 2017 and is due to end on the 1st of April 2017. The desired outcome of this action is to improve clients’ experience of services, working cohesively and consistently to support risks and the individuals’ recovery.” Source location 2017-0048-Response-by-Solent-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 Serious Incident Requiring Investigation policies to require investigators to engage all known stakeholders and services involved in a person’s care.
Verbatim wording from the response “In relation to issue 2, namely the report being incomplete because there was no input from the key worker at New Road, a number of actions have been put in place. In this particular instance, the incomplete reports were due to lack of input from both Substance Misuse Services and Adult Mental Health in relation to Serious Incident Requiring Investigation reports. In order to avoid this from happening again an action has been put in place to review the current Serious Incident Requiring Investigation policies for both Southern Health Foundation Trust and Solent NHS Trust to ensure the explicit requirement of Serious Incident requiring investigation investigators to engage with all key stakeholders/services who were/are involved in a person’s care, and offer them input into the investigation process.” Source location 2017-0048-Response-by-Solent-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Dual Diagnosis Policy across Southern Health Foundation Trust and Solent NHS Trust to include the joint-working process as staff best practice.
Verbatim wording from the response “The third action is to review the Dual Diagnosis Policy within Southern Health Foundation Trust and Solent NHS Trust to ensure that the action above is included within it as best practice for staff to follow. This action commenced on the 3rd of April 2017 and is due to end on the 1st of May 2017.” Source location 2017-0048-Response-by-Solent-NHS-Trust
Open published response
Concerns raised 1 Failure to provide a safe, clearly signposted pedestrian route through the health centre car park 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
Dennis Thomas Lavington · 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 Thomas Lavington, aged 84, was struck by a reversing taxi while crossing a health centre car park using a walking frame. He was admitted to hospital after suffering concussion, later developed hospital-acquired pneumonia and died; concern was raised that the car park layout created a potential conflict between pedestrians and vehicles.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a safe, clearly signposted pedestrian route through the health centre car park
Wider context from the report “The layout of the health centre car park leads to a potential conflict between pedestrians and car drivers. Whilst there is a drop off point outside the entrance, many of the patients are likely to be parking in the disabled parking spaces and they then have to cross the car park to reach the entrance. If there was a dedicated crossing or a marked path around the edge of the car park with improved signage, this would minimise the risk of a similar incident.
” Open source report
15 Mar 2016 Anna Mary Macfie Masson · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 2 Failure of the screening pathway to reliably identify people needing urgent treatment View source Failure to ensure consistent screening pathway practice across equivalent teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anna Mary Macfie Masson · 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
Anna Mary Macfie Masson, aged 67, died by suicide on 17 November 2015 after jumping into the path of a fast train at Micheldever railway station. The concerns related to whether a screening pathway for routine referrals was robust enough to identify people needing urgent treatment and whether it was applied consistently across equivalent teams.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the screening pathway to reliably identify people needing urgent treatment
Wider context from the report “(1) I received the Trust’s Root Cause Analysis Report relating to the treatment of routine referrals by general practitioners which disclosed a recently introduced screening pathway process. The evidence showed that screening potential service users is conducted by relatively junior members of staff and my concern is whether this process is robust enough to identify those who need urgent treatment .
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent screening pathway practice across equivalent teams
Wider context from the report “(2) It was unclear from the evidence given whether the screening pathway applied only to the local community mental health team or across all equivalent teams employed by the Trust . I consider that there should be a consistent practice in all teams .
” 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 Conduct a randomised audit across CMHTs to assess governance of the standardised screening process.
Verbatim wording from the response “Following completion of work to standardise the process we will undertake a randomised audit across the CMHTs to ensure governance around the screening process. We anticipate that this will be completed in September 2016.” Source location 2016-0108-Response-by-Southern-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 Standardise CMHT screening procedures, including appropriate staff expertise and multidisciplinary agreement of screening decisions.
Verbatim wording from the response “As part of the work identified during the investigation into the death of Mrs Masson, and following receipt of the Regulation 28 report the Trust has looked at the screening processes in all Adult Community Mental Health Teams (CMHT) and has identified that there is some variation across the Trust in terms of their screening processes. Consequently we have been working to review the CMHT Standard Operating Procedure (SOP) to ensure that a standard process is followed consistently across in all teams in the future to ensure the skill and expertise of those staff undertaking the screening is appropriate and that all decisions are agreed via a multi-disciplinary team discussion.” Source location 2016-0108-Response-by-Southern-Health-NHS-Trust
Open published response
29 Jan 2016 Louise Dawn Locke · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 7 Lack of an adequate system to collate and assess information from other agencies View source Failure to provide a consistent suicide prevention approach across service areas View source Failure to apply a multi-agency approach to high-risk individuals in Winchester View source Failure to carry out proper risk assessments before discharge View source Failure to offer adequate support at discharge View source Premature discharge from community mental health services View source Failure to review risk profiles and offer appropriate support View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Dawn Locke · 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
Louise Dawn Locke, a vulnerable adult with undiagnosed mental problems associated with alcohol dependency, died by suicide after hanging herself at her home in Winchester on 27 May 2015. The concerns included her premature discharge from mental health services without a proper risk assessment or adequate support, and inadequate systems for collating information across agencies to identify and support people at high risk.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an adequate system to collate and assess information from other agencies
Wider context from the report “(2) There was no adequate system in place to collate and assess information from other agencies such that her risk profile could be reviewed and appropriate support offered
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a consistent suicide prevention approach across service areas
Wider context from the report “(3) The systems already in place in some parts of Hampshire for a multi-agency approach to high risk individuals do not apply in Winchester and so opportunities to recognise these people are being missed. There should be a consistent approach by Southern Health to suicide prevention across all of the areas it serves.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply a multi-agency approach to high-risk individuals in Winchester
Wider context from the report “(3) The systems already in place in some parts of Hampshire for a multi-agency approach to high risk individuals do not apply in Winchester and so opportunities to recognise these people are being missed . There should be a consistent approach by Southern Health to suicide prevention across all of the areas it serves.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out proper risk assessments before discharge
Wider context from the report “(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to offer adequate support at discharge
Wider context from the report “(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Premature discharge from community mental health services
Wider context from the report “(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review risk profiles and offer appropriate support
Wider context from the report “(2) There was no adequate system in place to collate and assess information from other agencies such that her risk profile could be reviewed and appropriate support offered
” 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 Communicate through RCA learning events that risk assessments must occur before discharge.
Verbatim wording from the response “These plans will be brought back to the Clinical Director ████████ for sign off on the 21st April at the directors meeting. Risk assessments should take place prior to any discharge and this has been communicated through all learning events related to this RCA. The disengagement policy will be amended to reflect the process to follow disengagement from a second opinion.” Source location 2016-0026-Response-by-Southern-Health-NHS-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 Flag repeated emergency-department self-harm or overdose presentations to the Acute Mental Health Team for multidisciplinary safety and risk review.
Verbatim wording from the response “Since the inquest we have amended our Standard Operating Procedure (SOP) in relation to patients who attend an Emergency Department, for a self-harm or overdose incident on 3 occasions within a four week period. These people will now be flagged within the Acute Mental Health Team (AMHT) and will be discussed within the MDT to review safety, risk and need and to agree whether any changes to their current care plan is required.” Source location 2016-0026-Response-by-Southern-Health-NHS-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 Collate and share information from agencies about people with frequent or escalating contact through High Intensity User Groups.
Verbatim wording from the response “The wider information from other agencies that also have frequent and escalating contact with individuals will be collated and actioned through the High Intensity Usage Group and systems associated with this forum, as described below. There is two way sharing of information about this group of individuals between agencies in these forums.” Source location 2016-0026-Response-by-Southern-Health-NHS-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 Extend High Intensity User Groups to North and West areas and connect them with Acute Mental Health Team care planning across the Trust.
Verbatim wording from the response “These High Intensity User Groups are multi-agency forums and include representation from Police, Ambulance, Community Mental Health, Hampshire County Council Safeguarding and Emergency Department staff. The revised SOP also ensures that AMHT staff will engage with the High Intensity User groups in their local areas to support consistent care planning.” Source location 2016-0026-Response-by-Southern-Health-NHS-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 Formulate and obtain approval for standard arrangements ensuring patients seeking second opinions are not prematurely discharged and can access suitable appointments.
Verbatim wording from the response “The Adult Mental Health Management Team have discussed this and an action has been assigned to the Clinical Service Directors in each area to formulate a standard plan to ensure that patients requesting second opinions have access to these, and are not prematurely discharged if they advise that they are unable to attend their appointment. There is agreement across all areas that a second opinion offer should be individually negotiated to the needs of the service user, and that if someone alerts us that they cannot attend the appointment then other arrangements will be made to facilitate the appointment either through a different venue or through the consultant travelling to another area. The standard process will depend on the geography of each area and consultants working arrangements.” Source location 2016-0026-Response-by-Southern-Health-NHS-Trust
Open published response
2 Nov 2015 Connor Sparrowhawk · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2 Failure of RIO to support complete recording and accessibility of patients' epilepsy information View source Failure to maintain effective bathing observations for patients with epilepsy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Connor Sparrowhawk · 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
Connor Sparrowhawk died on 4 July 2013 at STATT after drowning following an epileptic seizure while in the bath; the jury found that neglect contributed. The report raises concerns about whether sight or sound observations during bathing can effectively prevent drowning in patients with epilepsy, and whether RIO adequately captures and makes accessible patients’ epilepsy histories.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of RIO to support complete recording and accessibility of patients' epilepsy information
Wider context from the report “2) The second matter of concern is in relation to RIO and the fact that there does not appear to be an appropriate prompt or place to record details about a patient's epilepsy/history . In Connor's case, this led to details of his epilepsy being placed on the care plan.
Even though there have been improvements, including the introduction of the epilepsy tool kit, it is not clear whether, even now, all the required information about epilepsy can be captured on RIO and therefore, is easily accessible to 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective bathing observations for patients with epilepsy
Wider context from the report “1) It appears that the current recommendation at the Trust is for patients with epilepsy to be able to choose to bath but to be the subject of sight/sound observations. There are obvious difficulties in respect of patient dignity with observations by sight. As far as observations by sound are concerned, it is envisaged that a member of staff will be sat outside the bathroom door while the patient takes a bath. I am concerned however that observations by sound alone may not prevent someone from drowning . A person can drown in seconds if they are rendered unconscious by an epileptic fit. It also seems to me that a member of staff in, for example, the corridor is likely to be distracted by other members of staff and patients and may also have an occasional requirement to obtain a drink or use the toilet etc. In reality, on a busy ward, particularly with a patient who has reasonably well controlled epilepsy, the concern is that close observation by sight/sound is unlikely to be maintained . I am concerned that this policy is simply setting the Trust up to fail.
I understand that a decision was taken sometime after Connor's death to stop bathing. I also understand however that the CQC when they carried out one of their inspections was critical of this decision due to the fact that the CQC are not in favour of blanket bans of this nature. I am sending a copy of this letter to the CQC for them to comment on.
My concern is therefore in relation to the effectiveness of bath time observations for patients with epilepsy.
” 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 Add a specific physical-health-risk prompt to the overarching RiO risk assessment form.
Verbatim wording from the response “It is important that staff record risks around all physical health problems and not just epilepsy. A change request has also been made with regards to the overarching RiO risk assessment form for mental health and learning disability services. This will provide a specific prompt for physical health risks to be noted. We expect this to be available in a future OpenRiO release planned to occur in March 2016. In the meantime, there is guidance available for staff within the comprehensive Learning Disability Service Specific Guidance for RiO which advises them that physical health risks (with specific mention of epilepsy) should be noted in the ‘Other Risk Behaviours’ section of the existing form. ████████ has undertaken considerable work to promote this guidance within the division.” Source location 2015-0445-Response-by-Southern-Health-NHS-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 Build and release electronic epilepsy assessment forms in OpenRiO for Learning Disability and other relevant Trust services.
Verbatim wording from the response “You were concerned that RiO, the electronic patient record, did not have an appropriate place to record details about a person’s epilepsy. This has been considered by ████████ who is an Informatics Clinician, the OpenRiO Learning Disability Clinical Lead and a Community Learning Disability Nurse by background.” Source location 2015-0445-Response-by-Southern-Health-NHS-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 Finalise and ratify the Trust-wide protocol for safe bathing and showering of people with epilepsy.
Verbatim wording from the response “The Clinical Director for Learning Disability Services, ████████, has led this piece of work alongside members of the Epilepsy Clinical Area of Practice group within the division. Although a comprehensive Epilepsy Map and Toolkit have been developed which cover all areas of risk, a decision has been made to write a new protocol specifically for bathing. This has been drafted by ████████, Consultant Nurse, again in conjunction with a range of practitioners. The document is called Protocol for the Safe Bathing and Showering of People with Epilepsy and has just been through a consultation process among senior clinical staff members. As a result of this, suggestions have been made as to some additions that are required to make it applicable to every speciality across the Trust rather than just the Learning Disability Division.” Source location 2015-0445-Response-by-Southern-Health-NHS-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 Promote Learning Disability Service Specific Guidance for recording physical-health risks, including epilepsy, in RiO.
Verbatim wording from the response “It is important that staff record risks around all physical health problems and not just epilepsy. A change request has also been made with regards to the overarching RiO risk assessment form for mental health and learning disability services. This will provide a specific prompt for physical health risks to be noted. We expect this to be available in a future OpenRiO release planned to occur in March 2016. In the meantime, there is guidance available for staff within the comprehensive Learning Disability Service Specific Guidance for RiO which advises them that physical health risks (with specific mention of epilepsy) should be noted in the ‘Other Risk Behaviours’ section of the existing form. ████████ has undertaken considerable work to promote this guidance within the division.” Source location 2015-0445-Response-by-Southern-Health-NHS-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 Collate results from epilepsy, bathing-risk and physical-health audits to inform further improvements.
Verbatim wording from the response “Compliance with policies and guidelines and with record keeping standards is assessed on an ongoing basis through management supervision and the peer review process. Audits are also regularly performed with an Epilepsy audit, bathing risk audit and physical health audit having been undertaken in the learning disability division in the last quarter. The results of these are being collated and will inform further improvements that are required.” Source location 2015-0445-Response-by-Southern-Health-NHS-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 Communicate the OpenRiO release and explain use of the electronic epilepsy forms through Trust-wide, divisional and governance channels.
Verbatim wording from the response “The release of the new version of RiO with the epilepsy forms will be accompanied by a comprehensive communication plan to ensure staff are aware of their availability. This will include the following:” Source location 2015-0445-Response-by-Southern-Health-NHS-Trust
Open published response
Concerns raised 2 Failure to formally consult the patient's GP about how, where, or whether to change treatment View source Failure to have proper regard to the patient's GP's views on treatment arrangements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
George Robert Vickery · 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
George Vickery fell after getting out of an ambulance outside Oak Park Community Clinic while attending for leg treatment, sustaining a broken hip and dying the next day in hospital. The concern was that the decision to treat him at the clinic rather than at home did not take account of his GP’s request that he be treated at home.
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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally consult the patient's GP about how, where, or whether to change treatment
Wider context from the report “That the decision to treat Mr Vickery at the clinic rather than in his own home (as had been the case previously) was taken without regard to a request from his GP that he should be treated at home, not at a clinic .
In my opinion, when assessing how and where a patient should be treated, or when assessing whether any changes should be made as to how and where a patient is treated, Southern Health's Integrated Community Services should formally consult with the Patient's GP and have proper regard to the GP's views on these matters.
” 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 Hampshire and Isle of Wight Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to have proper regard to the patient's GP's views on treatment arrangements
Wider context from the report “That the decision to treat Mr Vickery at the clinic rather than in his own home (as had been the case previously) was taken without regard to a request from his GP that he should be treated at home, not at a clinic .
In my opinion, when assessing how and where a patient should be treated, or when assessing whether any changes should be made as to how and where a patient is treated, Southern Health's Integrated Community Services should formally consult with the Patient's GP and have proper regard to the GP's views on these matters .
” Open source report
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