3 Jun 2026 Jack Horace BURTON · Prevention of Future Deaths report Worcestershire
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Concerns raised 3 Lack of standardised guidance for recording answers about possible medication side effects View source Lack of guidance on the relevance of smoking reduction rather than smoking cessation View source Lack of standardised guidance for asking questions about possible medication side effects View source
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Jack Horace BURTON · 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 Horace BURTON, who had schizophrenia and was prescribed Clozapine, died of Clozapine toxicity after stopping smoking while on holiday in North Yorkshire. Concerns included inconsistent medical accounts about the relevance of reducing smoking and a lack of standardised guidance for asking and recording information about possible medication side effects.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidance for recording answers about possible medication side effects
Wider context from the report “2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication . Practitioners can therefore make no record if no information is provided , which does not indicate whether questions were asked.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the relevance of smoking reduction rather than smoking cessation
Wider context from the report “1. There were inconsistent accounts provided to me by two consultant psychiatrists, about the relevance of reduction in smoking, rather than cessation of smoking , attributable to there being no guidance available to doctors on this issue .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidance for asking questions about possible medication side effects
Wider context from the report “2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication. Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked .
” 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 Re-issue the Clozapine Treatment Guidelines and clinic guidance to the mental health clinical workforce.
Verbatim wording from the response “In further response to the concerns raised by the Coroner, the Trust has re-issued both documents to the mental health clinical workforce. Follow-up actions will be undertaken to ensure that both newly appointed and existing staff are aware of, and comply with, the guidelines.” Source location Response from Herefordshire and Worcestershire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake follow-up to ensure newly appointed and existing staff are aware of and comply with both clozapine guidance documents.
Verbatim wording from the response “In further response to the concerns raised by the Coroner, the Trust has re-issued both documents to the mental health clinical workforce. Follow-up actions will be undertaken to ensure that both newly appointed and existing staff are aware of, and comply with, the guidelines.” Source location Response from Herefordshire and Worcestershire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain current Clozapine Treatment Guidelines addressing smoking cessation and smoking reduction effects on clozapine levels.
Verbatim wording from the response “Herefordshire and Worcestershire Health and Care Trust have Clozapine Treatment Guidelines in date and available on the Trust Intranet site.” Source location Response from Herefordshire and Worcestershire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Clozapine Clinic standard operating procedure and GASS to monitor and record clozapine side effects in electronic patient records.
Verbatim wording from the response “Herefordshire and Worcestershire Health and Care Trust have a standard operating procedure, Community Mental Health Team’s Clozapine Clinic Guidance and Promotion of Health & Wellbeing, this document is in date and available on the Trust intranet. Please find the document attached.” Source location Response from Herefordshire and Worcestershire NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Guidance on clozapine management during smoking reduction or cessation already exists, contrary to the concern that no guidance was available.
Verbatim wording from the response “1. There were inconsistent accounts provided to me by two Consultant Psychiatrists, about the relevance in reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue.” Source location Response from Herefordshire and Worcestershire NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Trust clozapine treatment guidelines address the effects of smoking reduction and cessation on clozapine levels.
Verbatim wording from the response “Herefordshire and Worcestershire Health and Care Trust have Clozapine Treatment Guidelines in date and available on the Trust Intranet site.” Source location Response from Herefordshire and Worcestershire NHS Trust
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6 Feb 2025 Katrina Veronica Francesca Insley · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Absence of a formal, documented handover system between hospital and Neighbourhood Team View source Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores View source
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AI-generated summary
Katrina Veronica Francesca Insley · 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
Katrina Insley died on 1 January 2024 at Alexandra Hospital, Redditch, from sepsis due to an infected pressure sore and pneumonia. The report identified concerns about the absence of a formal, documented handover system between hospital and the Neighbourhood Team, limited access to hospital records, and the resulting risk of delayed recognition and treatment of pressure sores, infection and sepsis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a formal, documented handover system between hospital and Neighbourhood Team
Wider context from the report “(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and follow up to be delayed. This increases the risk of wound infection and consequent sepsis.
(2) I am informed (letter received from HWHT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores
Wider context from the report “(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and follow up to be delayed. This increases the risk of wound infection and consequent sepsis.
(2) I am informed (letter received from HWHT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a handover form containing wound-care advice drawn from electronic patient-record and Tissue Viability records.
Verbatim wording from the response “In addition, the Acute Trust have developed a handover form (copy attached), which will detail wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue Viability records. This will be sent home with the patient and therefore will be available for them to share with professionals who attend their home, as an additional source of information alongside the Electronic Patient Record system.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send the wound-care handover form home with discharged patients for sharing with professionals providing care at home.
Verbatim wording from the response “In addition, the Acute Trust have developed a handover form (copy attached), which will detail wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue Viability records. This will be sent home with the patient and therefore will be available for them to share with professionals who attend their home, as an additional source of information alongside the Electronic Patient Record system.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review access uptake after all identified staff receive access and determine whether additional electronic patient-record licences are required.
Verbatim wording from the response “So far, 18 out of the 26 people identified as needing access, have been granted access but are not yet in full operational use. Once all access has been obtained as planned, this will be reviewed quickly to establish whether more licenses are required.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain electronic patient-record access for two staff members per Neighbourhood Team, including evening and night community nursing teams.
Verbatim wording from the response “The Trusts have further considered the impact of not having a shared records system, and the Health and Care Trust are in the process of obtaining access for 2 members of staff per Neighbourhood team (including Evening and Nights community nursing team) to the Acute Trusts Electronic Patient Record – ‘Sunrise’. The access will be given to staff who sit within Triage hubs in the Neighbourhood Teams and triage new referrals. This will enable them to gain detailed patient information, for example, regarding wounds.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
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14 Oct 2024 Caroline Ann STAITE · Prevention of Future Deaths report Herefordshire
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Concerns raised 3 Insufficiently robust procedures for sifting patients for consideration by Mind View source Failure to return patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested View source Lack of transparency and encouragement in the procedure for returning patients from Mind to Neighbourhood Mental Health Team care View source
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AI-generated summary
Caroline Ann STAITE · 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
Caroline Ann STAITE was recovered from the River Wye near the Canary Bridge, Hereford, after being reported in the river on 8 March 2024, and was pronounced deceased at 0241 hours on 9 March 2024. The concerns related to the robustness of procedures for considering patients for Mind, and to transparent arrangements for returning patients from Mind to the care of the Neighbourhood Mental Health Team.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust procedures for sifting patients for consideration by Mind
Wider context from the report “(1) The Neighbourhood Mental Health Team should ensure that their procedures are sufficiently robust regarding the sifting of patients for consideration by Mind .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to return patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested
Wider context from the report “(3) If so requested by the Mind worker the patient should be returned to the care of the Neighbourhood Mental Health Team and the involvement of the Mind worker discontinued .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of transparency and encouragement in the procedure for returning patients from Mind to Neighbourhood Mental Health Team care
Wider context from the report “(2) The procedure for the return of patients from Mind to the care of the Neighbourhood Mental Health Team should be transparent and encouraged if the Mind worker feels that is appropriate.
” 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 Co-produce and ratify a Standard Operating Procedure defining the Community Mental Health Link Worker role and safe support arrangements.
Verbatim wording from the response “Action:
Since this time our Community Service Manager, Diane Topham, who oversees our Neighbourhood Mental Health Team has worked closely with the Herefordshire MIND service to co-produce a Standard Operating Procedure (SOP) for the community Mental Health Link Worker Service in Herefordshire.” Source location 2024-0548 - Response from Herefordshire & Worcestershire NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Link Workers with established access to Neighbourhood Mental Health duty staff, team managers, clinical leads and weekly multidisciplinary meetings for care and risk concerns.
Verbatim wording from the response “Action:
The MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’ (registered professional) or Team Manager/ Clinical Lead, where they can identify any areas of concern with care and treatment plans.” Source location 2024-0548 - Response from Herefordshire & Worcestershire NHS
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26 Jun 2024 Nicola Jane Lacey · Prevention of Future Deaths report Herefordshire
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Concerns raised 1 Lack of clear, known procedures for employers concerning appropriate disclosure of colleagues' ongoing mental health difficulties View source
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AI-generated summary
Nicola Jane Lacey · Prevention of Future Deaths report
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Report summary
Nicola Jane Lacey lived alone and was found dead at her home after she failed to attend work on 30 December 2022; the inquest concluded that her death was suicide. The report raised concern about the need for clear procedures for employers on disclosing colleagues’ ongoing mental health difficulties, for the benefit of the individual and wider public safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear, known procedures for employers concerning appropriate disclosure of colleagues' ongoing mental health difficulties
Wider context from the report “(1) Procedures should be clear and known to employers concerning the appropriate disclosure of a colleagues ongoing mental health difficulties for the benefit of both the individual concerned and the safety of the wider public.
” 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 the working-hours and out-of-hours SOPs to the Trust’s Position of Trust Policy.
Verbatim wording from the response “To ensure this process is clear, known to staff and followed routinely we have developed 2 Standard Operating Procedures (SOPs), one within working hours and one for out of hours. These SOPs are now in place and will be added to our Position of Trust Policy. Please find both SOPs attached for your information.” Source location Response from Herefordshire and Worcestershire NHS
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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 separate working-hours and out-of-hours SOPs governing the process for staff disclosure decisions under the Position of Trust framework.
Verbatim wording from the response “In this situation where concerns arise the clinical team notify our Safeguarding team who then co-ordinate an appropriate discussion with professional advice and a decision is made using the Position of Trust Framework as to whether information is shared with an employer or not.” Source location Response from Herefordshire and Worcestershire NHS
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16 Feb 2024 Rosie Catherine YOUNG · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Failure to ensure that employees transporting patients detained under the MHA are familiar with and trained to apply the MHA Transportation Policy View source Failure to ensure that employees apply other MHA policies and procedures View source
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Rosie Catherine YOUNG · Prevention of Future Deaths report
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Report summary
Rosie Catherine YOUNG died on 8 November 2021 after sustaining a traumatic brain injury when she stepped from the rear door of a moving ambulance while being transported to a psychiatric unit. The inquest identified concerns about failures to record and communicate her previous incidents of jumping from moving vehicles, inadequate risk assessment and transport arrangements, and insufficient staff awareness and training regarding the Mental Health Act Transportation Policy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that employees transporting patients detained under the MHA are familiar with and trained to apply the MHA Transportation Policy
Wider context from the report “3) It seems that your Trust appeared at the time of these events to have had no system in place to ensure that those of your employees who dealt with the transportation of patients detained under the MHA were familiar with and trained to apply the provisions of the version of this Policy which was in force at the time . It is of concern therefore that if that remains the case, not only in relation to the MHA Transportation Policy, but in relation to other policies and procedures under the MHA, circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that employees apply other MHA policies and procedures
Wider context from the report “3) It seems that your Trust appeared at the time of these events to have had no system in place to ensure that those of your employees who dealt with the transportation of patients detained under the MHA were familiar with and trained to apply the provisions of the version of this Policy which was in force at the time. It is of concern therefore that if that remains the case, not only in relation to the MHA Transportation Policy, but in relation to other policies and procedures under the MHA , circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the WMAS Transportation policy through relevant clinical teams and update it on the intranet.
Verbatim wording from the response “I can confirm that following the adoption of the West Midlands Ambulance (WMAS) Transportation policy on 1 February 2024 that this has been disseminated through clinical teams who may need to use the policy. The policy has also been updated on our intranet. However, due to issues unrelated to this matter, the Trust now contract with an independent provider (E-Med) to convey patients who are liable to be detained under the MHA and so whilst we have the WMAS transportation policy in place, it may be used less frequently on a practical basis.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include applicable system-partner policies within the enhanced policy-management process.
Verbatim wording from the response “Part of the enhanced process will include management of policies written by system partners that are applicable to services within our organisation.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise Urgent Care local induction by documenting service-specific policies and obtaining staff read-and-understood confirmations.
Verbatim wording from the response “For further assurance in relation to this specific case, following discussion at the monthly Urgent Care Interface Meeting (attended by all Clinical Leads and Service Managers), it has been agreed to broadly standardise the local induction process while accepting that there are a number of policies/procedures that will be specific to certain teams. As a consequence of these discussions, all services in Urgent Care will now employ the following guiding principles in addition to the standard corporate induction process;” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain service-level spreadsheets recording clinical staff and communication of new or updated policies and procedures.
Verbatim wording from the response “For further assurance in relation to this specific case, following discussion at the monthly Urgent Care Interface Meeting (attended by all Clinical Leads and Service Managers), it has been agreed to broadly standardise the local induction process while accepting that there are a number of policies/procedures that will be specific to certain teams. As a consequence of these discussions, all services in Urgent Care will now employ the following guiding principles in addition to the standard corporate induction process;” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake current-state analysis and establish a tracker for clinical policies, including currency, ownership, equality assessment and service applicability.
Verbatim wording from the response “The Trust fully recognises that the process for clinical policy management requires improvement. This observation has also been made during our recent CQC inspection and forms part of our improvement plan to address these concerns. As an immediate action we are undertaking current state analysis over the next three months to establish a tracker for clinical policies that outlines:” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
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18 Sep 2023 Anthony John Friend · Prevention of Future Deaths report Worcestershire
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Concerns raised 8 Failure to remove unsuitable slings from the service user's property View source Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns View source Failure by incoming care providers to identify previous care providers and seek a handover View source Failure to provide handovers between care agencies about care needs and safety concerns View source Failure to communicate concerns about continued unsafe sling use in writing to care agencies View source Failure to ensure carers' participation in sling assessments View source Failure to discuss sling use with new carers View source Failure to demonstrate safer sling use to carers View source See 5 more concerns
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AI-generated summary
Anthony John Friend · 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
Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove unsuitable slings from the service user's property
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend , ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property ;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property ;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address , and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling . In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies” , but that it “was not something which we had ever done” ;
5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care. In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by incoming care providers to identify previous care providers and seek a handover
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”;
5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care . In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide handovers between care agencies about care needs and safety concerns
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies” , but that it “was not something which we had ever done” .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns about continued unsafe sling use in writing to care agencies
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers' participation in sling assessments
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ) ; and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss sling use with new carers
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling ;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate safer sling use to carers
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided ;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” 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 Introduce a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.
Verbatim wording from the response “We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.” Source location Response from Herefordshire and Worcestershire Health and Care
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 Create a standardised letter for service leads to send when patients or others resist removal of unsafe equipment, storing copies in electronic patient records.
Verbatim wording from the response “We have also designed a standardised template letter (a copy is attached for your information) for service leads to send to patients if our clinicians experience resistance when removing equipment from a patient’s home and these will be stored on our electronic patient record.” Source location Response from Herefordshire and Worcestershire Health and Care
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 and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.
Verbatim wording from the response “As a Trust we recognise that more timely action was required about removal of older slings so we have in partnership with a range of professionals designed a focus-on-card around a step by step guide for staff when they identify unsafe equipment in a patient’s home. This is a direct impact from this serious incident. This will act as a useful reminder document that staff will have access to when visiting patients in their homes and will be a vital part of new starter’s induction packs.” Source location Response from Herefordshire and Worcestershire Health and Care
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 operationalize a policy specifying timely removal of unsafe equipment from patients’ homes, with staff dissemination through team meetings and Trust-wide communications.
Verbatim wording from the response “As a Trust we recognise that at the time of this incident we did not have a robust policy and procedure in place to support our staff in the community with regard to the removal of unsafe equipment. Since the incident we have formulated a working group to design a new policy around equipment provision and this will cover the necessary steps and procedures for our staff, around timely removal of unsafe equipment from a patient’s home. We will have this new policy signed and operational by the 1st April 2024. A key element will be sharing this new policy which will be completed at individual team meetings and via our global all staff communication emails. Whilst we are developing the new policy we have issued more immediate instructions to staff via a focus on card approach.” Source location Response from Herefordshire and Worcestershire Health and Care
Open published response
2 Jun 2023 Nigel Harper · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Lack of staff understanding of cross-trust urgent mental health referral procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nigel Harper · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nigel Harper, who had been experiencing severe depression and anxiety and thoughts of self-harm, took an intentional overdose of prescribed sedative and hypnotic medications on 8 July 2022 and died in hospital on 23 July 2022. The report identified a lack of understanding between two NHS Trusts about urgent mental health referrals, resulting in an urgent assessment not being arranged as intended and a continuing risk of similar deaths.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding of cross-trust urgent mental health referral procedures
Wider context from the report “(4) I have concluded that the events described above arose out of a lack of understanding between the two NHS Trusts concerned ( Herefordshire & Worcestershire Health and Care NHS Trust ( HWCT ) and Gloucestershire Health and Care NHS Trust ( GHCT ) ) as to how each other’s mental health services are run – otherwise arrangements would have been made for Mr. Harper’s mental health to be assessed urgently, as was intended.
(5) If staff at HWCT and GHCT do not understand how to make urgent mental health referrals or requests for urgent mental health assessments to each other , there remains a risk that other deaths may occur in similar circumstances in the future.
” Open source report
×
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 the CRT operational policy to define inter-Trust referrals, urgency levels, transfer responsibilities, documentation, and comprehensive information for receiving services.
Verbatim wording from the response “In an attempt to prevent recurrence, we have reviewed/amended our CRT Operational Policy to include a specific section on inter-Trust referrals and transfers of care. In summary, if a patient presented in crisis to out-of-County emergency services/organisations our standard operating procedure has been updated to address this situation, as below:-” Source location Response from Herefordshire and Worcestershire Health and Care 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 Communicate the updated inter-Trust referral and transfer arrangements to staff in the affected services by email.
Verbatim wording from the response “On receipt of the joint Regulation 28, ████████, Operational Lead for Urgent Care (HWHCT) met with ████████, Deputy Director for Urgent Care Mental Health (GHCT) and ████████, Solicitor (HWHCT). The purpose of this meeting was to take a detailed examination of the circumstances surrounding the communication between both organisations and to work collaboratively on a suitable solution. As a result, changes to local policy have been made (outlined below) and communicated to those staff in the affected services by email dated 18 July 2023.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers its updated inter-Trust referral system robust and sufficient to prevent recurrence.
Verbatim wording from the response “In an attempt to prevent recurrence, we have reviewed/amended our CRT Operational Policy to include a specific section on inter-Trust referrals and transfers of care. In summary, if a patient presented in crisis to out-of-County emergency services/organisations our standard operating procedure has been updated to address this situation, as below:-” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust
Open published response
13 Mar 2023 Charlotte Comer · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Insufficiently robust safeguards against overriding MDT decisions View source Failure to fully understand how the care coordinator system failed View source Failure to establish how a senior clinician was able to override an MDT decision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Comer · 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
Charlotte Comer, who had significant mental health disorders and a history of suicide attempts and self-harm, left hospital before treatment for a self-inflicted arm wound and later took a substantial overdose of Propranolol and Amlodipine. She died on 20 July 2021 despite treatment. The principal concerns were instability and excessive workloads in the care coordinator system, including a five-month period without an appointed coordinator, and the failure to prevent a senior clinician from overriding a multidisciplinary team decision about specialist treatment.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust safeguards against overriding MDT decisions
Wider context from the report “(2) The erroneous decision to pause Charlotte’s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder was taken by a senior clinician acting on her own, despite a Multi-Disciplinary Team meeting having decided that the referral was appropriate. When asked about how the senior clinician could have overridden the MDT decision, the Trust’s Community Services manager for the Worcestershire Neighbourhood Teams told the inquest that he could not say whether the senior clinician was not aware of the correct decision-making procedure, or whether she was, but chose instead to ignore it. When asked whether the same issue could arise in future, he told the inquest that he himself would be in a position to prevent the senior clinician making the wrong decision, but could not guarantee that he would be made aware of the issue so as to be able to do so.
I am concerned that the Trust has not properly established how the senior clinician was able to override the MDT decision, and does not have a sufficiently robust system in place to ensure that MDT decisions cannot be overridden in this way in future.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully understand how the care coordinator system failed
Wider context from the report “(1) During the 2½ years in which Charlotte’s mental health care was provided by the Trust, she had total of 8 different care coordinators. Furthermore, in those 2½ years there was a 5 month period when Charlotte had no appointed care coordinator at all. The care coordinator role is particularly important for a patient with such a complex case history as Charlotte.
I heard evidence that at the time of these events, the Trust had been experiencing an unprecedented level of instability, with many staff who might have been expected to fulfil care coordinator roles going off sick or even leaving the service. The witness who had conducted the Trust’s own internal investigation into these events gave evidence that one of the major reasons for this instability was that staff were unable to cope with ever-increasing workloads. The Trust’s Community Services manager for the Worcestershire Neighbourhood Teams appeared to corroborate this in his evidence, confirming that whilst national guidelines recommend a maximum of 30 patients per care coordinator, at the time of these events the Trust’s care coordinators had around 100 patients each. Whilst he was able to provide some reassurance that a recent recruitment drive has reduced individual care coordinator caseloads to around 25 patients, he was unable to explain how individual caseloads had been able to reach the levels they did at the time of these events, and was unable to give accurate figures as to current levels of staff sickness/absence.
I am concerned that the Trust is unable to understand fully how the care coordinator system failed at the time of these events, and that it is therefore not in a position to guard against a repeat of these circumstances in the future.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish how a senior clinician was able to override an MDT decision
Wider context from the report “(2) The erroneous decision to pause Charlotte’s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder was taken by a senior clinician acting on her own, despite a Multi-Disciplinary Team meeting having decided that the referral was appropriate. When asked about how the senior clinician could have overridden the MDT decision, the Trust’s Community Services manager for the Worcestershire Neighbourhood Teams told the inquest that he could not say whether the senior clinician was not aware of the correct decision-making procedure, or whether she was, but chose instead to ignore it. When asked whether the same issue could arise in future, he told the inquest that he himself would be in a position to prevent the senior clinician making the wrong decision, but could not guarantee that he would be made aware of the issue so as to be able to do so.
I am concerned that the Trust has not properly established how the senior clinician was able to override the MDT decision , and does not have a sufficiently robust system in place to ensure that MDT decisions cannot be overridden in this way in future.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish mandatory multidisciplinary governance for specialist-service funding decisions, changes, recording, challenge and escalation.
Verbatim wording from the response “The Trust fully accepts that a lead clinician sought to cancel Charlotte’s Priory referral in error. Evidence of this human error was reflected in the original Root Cause Analysis (RCA) and, consequently, actions have been put in place for a new process for funding arrangements.” Source location Response from Herefordshire and Worcestershire Health and Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The revised MDT funding decision process is considered sufficient to prevent clinicians from unilaterally overriding specialist referral decisions.
Verbatim wording from the response “Any decisions regarding funding arrangements for specialist services are now established at weekly MDT meetings. Any proposed change to an application must therefore also be brought to a subsequent MDT meeting, and any clinician wishing to challenge or change the MDT decision must be present to make their case. Each decision or change, and the rationale for it, must be clearly and contemporaneously recorded in the patient’s clinical notes. This process ensures mandatory open discussion in a recorded forum (MDT) as a precondition for any change. If the MDT is unable to come to a consensus, the issue will be escalated to the Associate Director (or Deputy Associate Director in their absence) and the Associate Medical Director for a decision.” Source location Response from Herefordshire and Worcestershire Health and Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The key worker model and enhanced oversight systems are considered to address discontinuity of care and escalating risk without further changes.
Verbatim wording from the response “You have asked whether we have fully understood the circumstances that pertained at the time and how the resultant discontinuity of care contributed to Charlotte’s sad death. I believe Charlotte’s experience of multiple care coordinators is effectively addressed in part through the change to a key worker approach and the overall expansion of the team inherent in the Transformation. Further, though, we now have in place systems and processes to ensure that patients whose acuity is escalating can be appropriately overseen. The Worcester City “huddle” takes place twice-weekly and focuses on those in high-need groups taking into account acuity, diagnosis and other concerns or vulnerabilities such as high-risk medications.” Source location Response from Herefordshire and Worcestershire Health and Care
Open published response
20 Dec 2022 Carl Robert ELLSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Lack of a clear and safe system for GPs to contact mental health teams for urgent reviews View source Failure to arrange mental health practitioner contact without placing the burden on patients in crisis View source Lack of GP awareness of how to request urgent psychiatric reviews 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
Carl Robert ELLSON · 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
Carl Robert ELLSON was found deceased in a wooded area on 16 July 2022 after sustaining a fatal self-inflicted wound. He had been experiencing anxiety and insomnia and had presented with suicidal ideation shortly before his death. The concerns identified were that GP access to urgent mental health reviews was unclear and unsafe, that patients in crisis were expected to initiate contact with mental health practitioners, and that GPs were not fully aware of how to request an urgent psychiatric review.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear and safe system for GPs to contact mental health teams for urgent reviews
Wider context from the report “1. On 13/07/22 Dr Ellson's GP needed to arrange an urgent mental health review as Dr Ellson had presented with suicidal ideation. The GP had significant difficulties trying to contact the Mental health team with messages giving incorrect numbers. My concern is that the system for GPs to contact mental health teams for urgent reviews is not clear nor safe.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange mental health practitioner contact without placing the burden on patients in crisis
Wider context from the report “2. Once contact had been made and a request was made for Dr Ellson to be assessed by the mental health team, the system in place is for the patient to call the mental health practitioner. My concern is that the patient is likely to be in crisis, which is why a referral is being made, and the burden should not be put on them to make the call.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of how to request urgent psychiatric reviews
Wider context from the report “3. The GP caring for Dr Ellson on 13/07/22 was unaware that she could make a request for a psychiatric review of the patient. The inquest heard how this was not well known by local GPs. My concern is that GPs should be fully aware how to request an urgent psychiatric review for patients.
” Open source report
23 Mar 2022 Emily Jane CALDICOTT · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions 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
Emily Jane CALDICOTT · 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
Emily Jane Caldicott was admitted to hospital after an overdose and was later found unresponsive after tying a ligature around her neck. She died on 23 March 2020 from pneumonia and cerebral anoxia due to the application of a ligature. The principal concerns were that staff failed to adequately assess her capacity regarding Lorazepam, did not administer it in her best interests, and failed to remove the item used to make the ligature; the jury found these failures probably or possibly contributed to her death and identified a risk of future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions
Wider context from the report “(6) Although staff on Holt Ward were undoubtedly having to deal with a very difficult situation in this case, I am concerned that if a such a decision has to be made in similar circumstances in the future, staff may not apply the correct test under the Mental Capacity Act 2005 , and there is therefore a risk of future deaths occurring.
” Open source report
9 Mar 2020 Roy CAMPBELL · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Failure to properly carry out environmental checks for ward escape routes View source Failure to enshrine environmental checks in Trust policy and mandatory ward-staff training View source Failure to provide an adequate system for identifying visitors leaving wards 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
Roy CAMPBELL · 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
Roy Campbell, who had cardiac problems and dementia, was detained under the Mental Health Act and admitted to a hospital ward in July 2018. He left through an insecure gate after staff on another ward mistakenly treated him as a visitor; after being returned to the ward, he suffered cardiac arrest and died in hospital. Concerns included the risk of detained patients absconding because of inadequate visitor identification and environmental checks that were not properly carried out, embedded in Trust policy, or subject to mandatory staff training.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly carry out environmental checks for ward escape routes
Wider context from the report “(3) During the inquest I also heard evidence that environmental checks, introduced by Athelon ward to try to identify and remedy any means by which a determined patient could try to leave the secure confines of the ward, were not being carried out properly at the time of these events, and are still not enshrined in Trust policy, thereby ensuing staff receive mandatory training on it. I was concerned to be told that, only after evidence in this inquest was heard on Monday 2 March 2020, the current form being used to record such checks was revised and staff on both Athelon and Holt wards were instructed to start using it. I was surprised that these revisions were made at such a late stage, when the information given in evidence which led to those revisions must have been available to the Trust some time ago. I am also informed that it would take at least a further 2 months for the proper completion of this form to be enshrined into Trust policy.
(4) I am concerned that, unless and until these environmental checks become the subject both of Trust policy and of mandatory training for all ward staff, there remains a risk that the means by which a vulnerable patient might try to leave the confines of a ward may not be identified in time . If that patient were to be elderly and/or physically compromised, as Mr. Campbell was, this will lead to an increased risk of death in any such patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enshrine environmental checks in Trust policy and mandatory ward-staff training
Wider context from the report “(3) During the inquest I also heard evidence that environmental checks, introduced by Athelon ward to try to identify and remedy any means by which a determined patient could try to leave the secure confines of the ward, were not being carried out properly at the time of these events, and are still not enshrined in Trust policy , thereby ensuing staff receive mandatory training on it. I was concerned to be told that, only after evidence in this inquest was heard on Monday 2 March 2020, the current form being used to record such checks was revised and staff on both Athelon and Holt wards were instructed to start using it. I was surprised that these revisions were made at such a late stage, when the information given in evidence which led to those revisions must have been available to the Trust some time ago. I am also informed that it would take at least a further 2 months for the proper completion of this form to be enshrined into Trust policy.
(4) I am concerned that, unless and until these environmental checks become the subject both of Trust policy and of mandatory training for all ward staff , there remains a risk that the means by which a vulnerable patient might try to leave the confines of a ward may not be identified in time. If that patient were to be elderly and/or physically compromised, as Mr. Campbell was, this will lead to an increased risk of death in any such patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate system for identifying visitors leaving wards
Wider context from the report “(1) During the inquest, I heard evidence from ████████ who conducted the Trust's own investigation into this incident that, not long after Mr. Campbell's death, the Trust had introduced a visitor book system for use in the relevant wards at Newtown Hospital. It was originally thought by the Trust that this system would have been sufficient to prevent patients leaving a ward as Mr. Campbell had done. It was not until evidence was given at the first (aborted) inquest into Mr. Campbell's death in October 2019, however, that the Trust came to the view that this system was inadequate , and further work was carried out which came up with a solution involving the use of an electronic system which will use photographs to identify whether a person who wishes to leave the ward has previously been admitted as a visitor. I am told that, whilst the business case for the proposed new system has been submitted, approval is awaited for it can be implemented .
(2) I therefore remain concerned that, unless and until such a system has been approved and put in place, there remains a risk of detained patients absconding from wards at Newtown Hospital and, if elderly and/or physically compromised as Mr. Campbell was, an increased risk of death in any such patient.
” 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 Procure and install electronic visitor-identification systems across the Trust’s Worcestershire and Herefordshire wards and rehabilitation units.
Verbatim wording from the response “1) During the inquest, I heard evidence from ████████, who conducted the trust’s own investigation into this incident that, not long after Mr Campbell’s death, the trust had introduced a visitor book system for use at the relevant wards at Newtown Hospital. It was originally thought by the trust that this system would be sufficient to prevent patients leaving the ward as Mr Campbell had done. It was not until evidence was given at the first (aborted) inquest into Mr Campbell’s death in October 2019, however, that the trust came to the view that this system was inadequate, and further work was done, which came up with a solution involving the use of an electronic system, which will use photographs to identify whether a person wishing to leave the ward, had previously been admitted as a visitor.” Source location 2020-0059-Response-from-Worcestershire-Health-and-Care-NHS-Trust_Redacted
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 ward-specific environmental checklists and procedures as Trust policy, including shift-start and shift-end nurse-in-charge checks and joint handover checks.
Verbatim wording from the response “The form which had been introduced in October 2019 was further amended by the Ward Manager, who was present at Court on Monday 2nd March 2020, and approved by a senior manager within the trust, that same day. By the morning of Tuesday 3rd March 2020, the new amended form had been sent to Athelon Ward, and New Haven ward (a specialist dementia care unit) and staff had been instructed to use the new form with immediate effect.” Source location 2020-0059-Response-from-Worcestershire-Health-and-Care-NHS-Trust_Redacted
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 Train ward staff on the ward-specific environmental checklists and policy through new-starter induction and existing-staff supervision sessions.
Verbatim wording from the response “In relation to training, the Trust have very specific general mandatory training which is covered across all services. It would not be appropriate to include the training on the environmental forms as part of the trusts mandatory training. Nor would it be possible to add it to the general list of mandatory training due to the differing nature of the forms.” Source location 2020-0059-Response-from-Worcestershire-Health-and-Care-NHS-Trust_Redacted
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 A single environmental checklist cannot safely be used across all wards because each ward has different environmental factors and risks.
Verbatim wording from the response “This form and procedure has now been enshrined into policy, and a copy of the updated policy is enclosed herewith for your consideration. You will note that there are several different environmental checklists in the appendix to the policy. As each ward under the control of the trust has different environmental factors and risks, it is not possible, or safe, to have one single form for all wards. Therefore, as it is now trust policy to use the forms, different forms have been introduced for each ward, which are relevant for the potential risks on that particular ward.” Source location 2020-0059-Response-from-Worcestershire-Health-and-Care-NHS-Trust_Redacted
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 Environmental-checklist training cannot be added to general mandatory training because ward forms differ; it will instead be covered through induction and supervision.
Verbatim wording from the response “In relation to training, the Trust have very specific general mandatory training which is covered across all services. It would not be appropriate to include the training on the environmental forms as part of the trusts mandatory training. Nor would it be possible to add it to the general list of mandatory training due to the differing nature of the forms.” Source location 2020-0059-Response-from-Worcestershire-Health-and-Care-NHS-Trust_Redacted
Open published response
29 Jul 2019 Alistair Patrick McDonald · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 8 Failure to account for partial disclosure of symptomology and history View source Lack of a specific action plan for failed communication with the patient or family View source Lack of a specific plan for unsuccessful referrals to other services View source Failure to obtain a broad assessment by an experienced psychiatrist View source Lack of a plan to review and manage the patient’s combined self-harm, suicidal intent and stress-related difficulties View source Failure to maintain communication with the patient and family for review when mental state deteriorates View source Inadequate specific deliberate self-harm or suicidal ideation criteria View source Failure to obtain detailed feedback from referred services about attendance and progress View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alistair Patrick McDonald · 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
Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for partial disclosure of symptomology and history
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history .
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific action plan for failed communication with the patient or family
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific plan for unsuccessful referrals to other services
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain a broad assessment by an experienced psychiatrist
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist .
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture , which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a plan to review and manage the patient’s combined self-harm, suicidal intent and stress-related difficulties
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain communication with the patient and family for review when mental state deteriorates
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate specific deliberate self-harm or suicidal ideation criteria
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain detailed feedback from referred services about attendance and progress
Wider context from the report “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted
2. The lack of a specific plan for referrals to other services which proved unsuccessful
3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist.
4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates
5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress
6. Recognising that some patients will only make partial disclosure of their true symptomology and history.
7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this
8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this.
” 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 all Choice assessments in a weekly multidisciplinary team meeting to support shared outcome decisions.
Verbatim wording from the response “Since 2017 the service has introduced a process whereby all Choice assessments are reviewed in the weekly Multidisciplinary Team Meeting (MDT). This meeting is attended by all the disciplines working within the service which includes nurses, psychologists, psychotherapists and psychiatrists. This provides a forum for case discussion with a shared outcome decision.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-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 The GP is responsible for initial contact and referral to more specialist services, rather than the CAMHS service obtaining detailed feedback.
Verbatim wording from the response “The Worcestershire CAMHS Service has reviewed as to if it is realistic and achievable to follow up and obtain detailed feedback from each service that a patient is referred to. The Service is not commissioned to do this and it is the role of the GP to be the initial point of contact for a person and to refer to more specialist services as required.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-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 Systems and processes introduced since 2017 are considered sufficient to address the overall position and psychiatry concern.
Verbatim wording from the response “Since 2017 the service has introduced a process whereby all Choice assessments are reviewed in the weekly Multidisciplinary Team Meeting (MDT). This meeting is attended by all the disciplines working within the service which includes nurses, psychologists, psychotherapists and psychiatrists. This provides a forum for case discussion with a shared outcome decision.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-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 Follow-up contact was not expected because the patient was discharged after assessment and signposted to alternative services.
Verbatim wording from the response “Following the Choice assessment undertaken on the 12th April 2016 Mr Alastair McDonald was discharged with CAMHS following having received signposting information of alternate services. A summary of the assessment and the outcome was detailed in a letter which was sent to both Mr Alastair McDonald and his GP.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The service is not commissioned to obtain detailed feedback from every service to which patients are referred.
Verbatim wording from the response “5. Obtaining detailed feedback from the services the patient is referred to, to check on attendance and progress” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-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 The assessment and communication arrangements were considered reasonable and proportionate, so no further action was identified.
Verbatim wording from the response “The Choice assessment was attended by the mother of Mr Alastair McDonald, and the detailed assessment notes that her views were taken into consideration in line with the overall formulation of the assessment and outcome.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-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 The actions taken regarding partial disclosure were considered reasonable and proportionate, so no further action was identified.
Verbatim wording from the response “As previously stated the staff working within the CAMHS SPA are experienced mental health practitioners from a wide range of professional backgrounds, with extensive support and supervision arrangements in place. It is not unusual for patients to not fully disclose the extent of their symptomology. Clinicians are skilled in assessing patients holistically, through a range of mechanisms.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-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 Obtaining detailed feedback after signposting was considered unrealistic and an inappropriate use of resources.
Verbatim wording from the response “On average the CAMHS SPA service receives 210 referrals a month.
Alongside this we have approximately 1500 children under the care of CAMHS.” Source location 2019-0257-Worcestershire-Health-and-Care-NHS-Trust
Open published response
9 Feb 2018 Gail Ann Bannister · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure of the care co-ordinator to see the patient View source Insufficient telephone access to the care team during a crisis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gail Ann Bannister · 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
Gail Ann Bannister had a long history of fluctuating mental health and experienced deterioration after her father’s illness and death. She died by suicide, with the medical cause of death recorded as hanging. Concerns included that her care coordinator did not see her after appointment, undermining the intended care arrangement, and that it took several hours for her husband to reach the care team during a crisis because of a known single-phone-line problem.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the care co-ordinator to see the patient
Wider context from the report “(1) The rationale behind discharging Mrs Bannister from the HTT to CARS was that she had been seeing too many different people. It was felt that by concentrating her care in the hands of the community consultant psychiatrist and a Care Co-ordinator, who would arrange the psycho-social services she would benefit from, this would improve her treatment. The fact that the care co-ordinator did not see her frustrated and undermined this approach.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient telephone access to the care team during a crisis
Wider context from the report “(2) During the inquest I was told that the deceased's husband tried to speak to members of the care team who were based at the Studdart Kennedy centre when a crisis developed. It took him several hours to get through. I was told there is only one phone line and that this is a known and recurring problem .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an initial review of the existing telephone system.
Verbatim wording from the response “An initial review of the current system has already taken place and a contractor survey of Studdart Kennedy House has been agreed and funded by Worcestershire County Council (who own the building). This costings survey was undertaken on 21st and 22nd March 2018, however has not yet been received by the Trust.” Source location 2018-0039-Response-Worcestershire-Health-and-Care-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 Provide Adult Mental Health staff with a mobile telephone for contacting the site or duty worker and communicate its use and contact numbers to all staff.
Verbatim wording from the response “In the meantime, interim measures have been implemented, consisting of a mobile telephone being used by Adult Mental Health staff to use to contact the site/duty worker and communication has been given to all staff to advise them of this interim measure and the appropriate contact telephone numbers to use.” Source location 2018-0039-Response-Worcestershire-Health-and-Care-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 Install a digital VOIP telephone system with call waiting and automatic call forwarding or transfer.
Verbatim wording from the response “An action plan has been put in place to install a telecommunications system which will provide a digital telephone system (VOIP). This will enable call waiting and call forward/transfer automatically.” Source location 2018-0039-Response-Worcestershire-Health-and-Care-NHS-Trust
Open published response
30 Nov 2016 Emma Louise TIMBRELL · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Lack of affordable access to out-of-hours telephone support for increased suicidal ideation 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
Emma Louise TIMBRELL · 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
Emma Louise TIMBRELL, who had a significant mental health history, died by hanging at her home; the inquest concluded that her death was suicide. A concern was that she might not have been able to afford the out-of-hours telephone call provided for use if her suicidal ideation increased.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of affordable access to out-of-hours telephone support for increased suicidal ideation
Wider context from the report “(1) the deceased was given an out of hours telephone number for use should her suicidal ideation increase . However she was known to have limited finances and there was a concern that she would not have been able to afford to make the telephone call if it had become necessary .
” Open source report
7 Apr 2016 Matthew Colin SARGENT · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to inform Healthcare staff when prisoners arrive with an ACCT history View source Failure to review available historical prisoner information at initial presentation View source Lack of meaningful engagement between Personal Officers and individual prisoners View source Failure to supply Prisoner Escort Records to Healthcare staff at reception View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Colin SARGENT · 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
Matthew Colin SARGENT was a serving prisoner who died in his cell at some time between 25 and 26 September 2014. The jury concluded that he committed suicide and raised concerns about the systematic, accurate and clear sharing of historical and current information between prison and healthcare departments.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform Healthcare staff when prisoners arrive with an ACCT history
Wider context from the report “(3) There was a concern that Healthcare staff were not made aware of prisoners who arrive with an ACCT history and it was suggested that Healthcare should be informed in all cases where a prisoner arrives at reception with an ACCT history so that there is a continued sharing of pertinent information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review available historical prisoner information at initial presentation
Wider context from the report “(2) There was a concern that historical information which was available to Officers and Healthcare staff was not reviewed when the prisoner first presented at the prison and it was suggested that it would be beneficial if there was an instruction that any member of staff dealing with a prisoner who had access to historical information should make some enquiry as to that historical information so as to inform them of both the present and past risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful engagement between Personal Officers and individual prisoners
Wider context from the report “(1) The Personal Officer of Mr Sargent appeared to have had little to do with him . It was suggested that there should regular meetings between Personal Officers and individual prisoners so that a more indepth knowledge of individual prisoners could be obtained as shared.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supply Prisoner Escort Records to Healthcare staff at reception
Wider context from the report “(4) There was a concern that the Prisoner Escort Record (highlighting concerns and risks) was not supplied to the Healthcare Department and nurses at reception . It was suggested that this should be an imperative requirement for the further sharing of relevant information.
” Open source report
18 Mar 2016 Jonathan James LANDER · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure of governance procedures to ensure action plans are followed through View source Lack of follow-up procedures for individuals discharged from one service to another View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathan James LANDER · 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
Jonathan James Lander was killed on 28 April 2015 when he was struck by a train on tracks near Blackbridge, Worcester Road, Hartlebury. The principal concern was the absence of a policy or procedure for following up individuals seen by one service and then discharged to another service, and that the identified action plan had not been implemented.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance procedures to ensure action plans are followed through
Wider context from the report “(1) That there is not in place any policy or procedure for the following up of individuals who are seen by one service and thereafter discharged to another service.
In the course of the inquest I was provided with a Root Cause Analysis which identified the failing mentioned above and which contained an action plan indicating that such a policy/procedure was to be implemented by September 2015.
I was told in the course of the inquest that that policy/procedure has not been implemented. I was left with the sense that this is still to be considered but there appears to be no sense of urgency.
I was further told that the Trust has a governance procedure to ensure that action plans are “followed through” but it seems to be clearly the case that this has not worked either .
I respectfully suggest that you consider urgently the necessity for such a procedure / policy and to implement it.
(2)
(3)
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up procedures for individuals discharged from one service to another
Wider context from the report “(1) That there is not in place any policy or procedure for the following up of individuals who are seen by one service and thereafter discharged to another service .
In the course of the inquest I was provided with a Root Cause Analysis which identified the failing mentioned above and which contained an action plan indicating that such a policy/procedure was to be implemented by September 2015.
I was told in the course of the inquest that that policy/procedure has not been implemented . I was left with the sense that this is still to be considered but there appears to be no sense of urgency.
I was further told that the Trust has a governance procedure to ensure that action plans are “followed through” but it seems to be clearly the case that this has not worked either.
I respectfully suggest that you consider urgently the necessity for such a procedure / policy and to implement it.
(2)
(3)
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an embedded lessons database containing Root Cause Analysis action plans and completion evidence, with Governance Team monitoring.
Verbatim wording from the response “I can advise in relation to a governance procedure to implement the Action Plans set out in individual Root Cause Analyses that the Trust now has an Embedded Lessons Database. All the Action Plans set out in individual Root Cause Analyses are now uploaded to that database together with evidence of completed actions. This database is monitored by the Governance Team based in the Adult Mental Health and Learning Disability Service Delivery Unit.” Source location J-Lander-Response
Open published response
30 Nov 2015 Stephen Martin ADAMS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to record suicide risk assessment in risk assessment documents 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
Stephen Martin ADAMS · 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
Stephen Martin ADAMS was being cared for by the Home Treatment Team of Worcestershire Health and Care NHS Trust when he died by suicide by hanging at his home. The inquest identified that the suicide-risk assessment section of a Mental Health Liaison Team risk assessment document had not been completed, and that risk assessment was instead inferred from the worker’s actions.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record suicide risk assessment in risk assessment documents
Wider context from the report “(1) It emerged during the inquest that the Risk Assessment document completed by the Mental Health Liaison Team worker was not complete in as much as the box indicating the assessment of suicide risk had not been completed .
The witness indicated that many workers do not complete this box and the assessment of risk is to be extrapolated from the actions taken by the worker .
No where on the document is the assessment of risk to be found .
” Open source report
26 Oct 2015 Wayne Patrick O'NEILL · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to account for asthma contraindications when prescribing propranolol View source Failure to prevent reintroduction of psychotropic medications contraindicated in combination View source Failure to recognise the toxic significance of medication combinations during reception screening View source Failure to perform ECG traces for prisoners receiving the specified medication combination View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wayne Patrick O'NEILL · 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
Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for asthma contraindications when prescribing propranolol
Wider context from the report “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time .
The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline.
An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination.
An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them.
It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised.
Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval.
The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication.
Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent reintroduction of psychotropic medications contraindicated in combination
Wider context from the report “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time.
The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline.
An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination.
An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them .
It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised.
Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval.
The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication.
Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the toxic significance of medication combinations during reception screening
Wider context from the report “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time.
The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline.
An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination.
An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them.
It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised.
Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval.
The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication .
Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform ECG traces for prisoners receiving the specified medication combination
Wider context from the report “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time.
The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline.
An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination.
An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them.
It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised.
Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication . This would reveal whether there was any prolongation of the QT interval.
The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication.
Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide routine annual ECGs to patients prescribed antipsychotic medicines, including relevant interacting combinations.
Verbatim wording from the response “• All patients prescribed any single or multiple anti-psychotic medication(s) and when prescribed in combination with other medications (such as tricyclic anti-depressants, erythromycin etc.) that have a propensity to increase the QT interval, will receive a routine, annual ECG as part of their package of care (there is a 12 monthly physical health review of mental health service users and the ECG forms part of this arrangement). This is already in place and was in place prior to Mr O’Neill’s inquest. The Lead Pharmacist at HMP Long Lartin will sample audit this by 31 January 2016 to ensure that all people who should have received an ECG have done so.” Source location 2015-0444-Response
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 Sample-audit annual ECG provision for all patients who should have received one.
Verbatim wording from the response “• All patients prescribed any single or multiple anti-psychotic medication(s) and when prescribed in combination with other medications (such as tricyclic anti-depressants, erythromycin etc.) that have a propensity to increase the QT interval, will receive a routine, annual ECG as part of their package of care (there is a 12 monthly physical health review of mental health service users and the ECG forms part of this arrangement). This is already in place and was in place prior to Mr O’Neill’s inquest. The Lead Pharmacist at HMP Long Lartin will sample audit this by 31 January 2016 to ensure that all people who should have received an ECG have done so.” Source location 2015-0444-Response
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 whole-nursing-team training to recognise medicines requiring ECG referral.
Verbatim wording from the response “• Training will be provided to the whole Nursing team with regard to recognizing medicines that should indicate a referral for an ECG. These medicines might readily be recognized by a Mental Health Nurse but not necessarily by a Primary Care nurse.” Source location 2015-0444-Response
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 Book ECGs when antipsychotic treatment is initiated and provide new receptions taking antipsychotics with an ECG within one month of arrival.
Verbatim wording from the response “• All patients initiated on anti-psychotic medicines at HMP Long Lartin will receive an ECG booked at the time the prescription is made and all new receptions on anti-psychotic medications will receive an ECG within one month of arrival at the prison.” Source location 2015-0444-Response
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 Share the medicines-regulatory alert on prescribing medication combinations with all HMP Long Lartin prescribers.
Verbatim wording from the response “Whilst the combination of psychotropic medication had originally been prescribed at HMP Birmingham, the Medicines Healthcare Regulatory Authority alert relating to the prescribing of certain medications, has been shared with all of our prescribers at HMP Long Lartin to reinforce awareness of prescribing combinations of such medication.” Source location 2015-0444-Response
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 an additional ECG when a patient's antipsychotic medication is changed, regardless of the annual ECG date.
Verbatim wording from the response “• Patients who are prescribed anti-psychotic medication, whose medication is changed, will receive an ECG even if they have already received their annual ECG.” Source location 2015-0444-Response
Open published response
18 Sep 2015 Liam SMITH · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 5 Limited healthcare staff interaction with prisoners at high risk from drug use View source Failure by healthcare staff to read relevant sections of System 1 notes View source Failure to disseminate relevant medical risk information to staff involved in prisoner care View source Failure to follow mandatory ACCT procedures for prisoners at risk of self-harm View source Failure of the System 1 summary page to display relevant important information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Liam SMITH · 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
Liam Smith was admitted to HMP Hewell on 7 August 2014 and died after taking a combination of prescribed and illicitly obtained medication in his cell. The concerns included possible failures to follow mandatory ACCT procedures, inadequate dissemination and recording of medical information, and limited healthcare interaction with high-risk drug users, potentially resulting in warning signs being missed.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited healthcare staff interaction with prisoners at high risk from drug use
Wider context from the report “(4) Evidence suggested only limited interaction between members of Healthcare Staff and prisoners who were deemed as "high risk drug users" with a concern that warning signs are missed
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to read relevant sections of System 1 notes
Wider context from the report “(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate relevant medical risk information to staff involved in prisoner care
Wider context from the report “(2) Evidence was given that certain medical information which arrived at the prison with Mr Smith was not disseminated to those in reception for those who had later dealings with him which meant that they were unaware of the potential risk of suicide or self harm. It was suggested by some witnesses that documentation "goes astray" and is only found much later .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow mandatory ACCT procedures for prisoners at risk of self-harm
Wider context from the report “(1) Evidence suggested that Mr Smith was at risk of inadvertant self harm and that therefore in accordance with PSI64/2011 ACCT procedures should have been opened in respect of him. Witnesses confirmed their understanding of that mandatory requirement but indicated that they would use their clinical judgement in deciding whether or not to open an ACCT. It is of concern that staff may therefore may therefore not be following mandatory PSI instructions and that prisoners are not receiving appropriate protection by way of the ACCT process .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the System 1 summary page to display relevant important information
Wider context from the report “(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information .
” Open source report
20 Mar 2015 James Paul COLTON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 7 Failure to provide prescribed analgesia when required View source Inadequate communication between healthcare nurses and doctors View source Failure to appropriately review care and treatment View source Failure to reassess diagnoses and escalate treatment despite continuing clinical decline View source Inadequate healthcare workload capacity for required clinical work and reviews View source Failure to maintain a coherent care plan View source Lack of continuity of care 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
James Paul COLTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Paul COLTON was a serving prisoner who became critically unwell on 29 August 2013 after a period of deteriorating health and died two days later in hospital. Concerns included failure to revisit his diagnosis or escalate treatment, inadequate analgesia, poor continuity and communication of care, and an extremely heavy workload affecting healthcare provision.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prescribed analgesia when required
Wider context from the report “(2) The procedure and processes for providing Mr Colton with adequate analgesia were defective and there were occasions when Mr Colton did not receive Tramadol to control his pain . This meant that his last days in prison were distressing and increasingly painful for him to the extent that he was at times unable to get off his bed to receive medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between healthcare nurses and doctors
Wider context from the report “(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors , and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately review care and treatment
Wider context from the report “(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess diagnoses and escalate treatment despite continuing clinical decline
Wider context from the report “(1) The doctors and nurses at the prison failed to properly diagnose, treat and care for Mr Colton in that they assumed that the diagnosis of mechanical back pain was accurate and took no steps to revisit the diagnosis or to escalate his treatment despite his obvious continuing decline . The failure to consider alternate diagnosis led to him missing his developing cancer and which may, therefore, have contributed to his early death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate healthcare workload capacity for required clinical work and reviews
Wider context from the report “(4) The evidence given was that there was an extremely heavy workload which meant (to quote one of the GP's who gave evidence) that he was unable to get on top of the work that was required of him and that reviewing prisoners in Healthcare was not a priority .
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a coherent care plan
Wider context from the report “(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care . There appeared to be no appropriate review of Mr Colton's care or 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care
Wider context from the report “(3) There appeared to be no continuity of care for Mr Colton , little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or treatment.
” 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 Assign named nurses to inpatient patients and two nurses to each normal-location wing to improve continuity of care.
Verbatim wording from the response “I recognise that in Mr Colton’s case there was a lack of continuity of care and I am able to notify you that every patient who is on the inpatient facility has a named nurse and this is identified on each cell door so that the discipline officers are also aware of the identity of the named nurse. For those individuals who are on normal location, there are two nurses assigned to each wing so that there is a greater continuity of care for all prisoners. There are also now regular nursing meetings to discuss individual patients that take place both in respect of physical and mental health patients.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-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 Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.
Verbatim wording from the response “Importantly, a couple of study sessions were held in which staff were taken through the case notes of Mr Colton and had an opportunity to discuss learning identified and how they may act in future situations. Whilst there are a number of learning objectives for the day, principally, staff were asked to be open and to be curious in clinical situations. I understand from my Deputy Head of Healthcare at HMP Long Lartin that staff still talk about the learning generated from this case and in the last week there has been an example of staff raising an issue and being encouraged to consider alternative options.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide weekly opportunities for prison sessional GPs to discuss cases and share good practice.
Verbatim wording from the response “At HMP Long Lartin, the GPs who provide sessional cover do have a weekly opportunity when they are both in the prison at the same time to discuss individual cases and share good practice. I consider that this is a positive move as well as formalising the new process for the obtaining of clinical supervision, which I anticipate will be through the South Worcestershire Federation. I consider that this provides adequate support for any individual clinician. Overall, I do consider that it is entirely appropriate for a clinical director from a different specialism (psychiatry) to manage other doctors from other specialties. If this was not appropriate we would inevitably have a position where we had to have lead clinicians for every type of professional within the organisation and I think that this would neither be desirable nor an appropriate use of scarce public funds.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-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 Discuss introducing further care-planning training and adapting SystmOne to support improved practice.
Verbatim wording from the response “I understand that you have been made aware as part of the action plan of an audit that took place in respect of care planning in January 2014 which showed an improvement in previous performance. However, I am not complacent about the need to ensure effective care planning and would confirm that the Trust has now appointed a quality and safety lead for offender healthcare as well as a new lead for SystmOne, our prison patient record, both of whom will work across the three prisons that this Trust provides healthcare in respect of and ensure best practice in areas such as care planning audits, improving our functionality and training on the patient records system. Discussions are taking place in the Trust as to introducing some further training on care planning and how SystmOne may be adapted to support improved practice in this area.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-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 Conduct a new inpatient-prisoner standard operating process with reviews of previous entries, tests, and patient care.
Verbatim wording from the response “As part of our continuing efforts to provide safe, high quality care in all of our services, I was keen to share with you some recent initiatives. A new standard operating system for inpatient prisoners is being conducted, at which time a review of previous entries is conducted. This is an additional review aimed at ensuring that no significant issues or tests are missed, as well as reviewing patient care. Further, the Deputy Head of Healthcare has identified an opportunity to accompany the Prison’s Disability Liaison Officer when undertaking her activities, to raise awareness of the healthcare function, especially for hard to reach groups, as well as identifying any issues being raised about the healthcare provision.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-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 Appoint quality and safety and SystmOne leads to support care-planning audits, record-system functionality, and staff training across three prisons.
Verbatim wording from the response “I understand that you have been made aware as part of the action plan of an audit that took place in respect of care planning in January 2014 which showed an improvement in previous performance. However, I am not complacent about the need to ensure effective care planning and would confirm that the Trust has now appointed a quality and safety lead for offender healthcare as well as a new lead for SystmOne, our prison patient record, both of whom will work across the three prisons that this Trust provides healthcare in respect of and ensure best practice in areas such as care planning audits, improving our functionality and training on the patient records system. Discussions are taking place in the Trust as to introducing some further training on care planning and how SystmOne may be adapted to support improved practice in this area.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-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 Assess offender-healthcare nursing numbers against workload and headcount.
Verbatim wording from the response “In respect of the workload of clinicians at the prisons, there is no national guidance as to staffing levels within prison environments. You may be aware that for other inpatient areas there is a NICE accredited tool entitled Safer Nurse Care Tool (SNCT) which provides a framework for assessing the number of qualified and unqualified staff on a particular ward. As a result of having no national guidance for identifying the establishment, the Trust is undertaking an assessment of nursing numbers in offender healthcare based upon the range of task undertaken and the headcount. The Trust is also having discussions about the assessment of our other medical inputs involving our commissioners.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-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 Minute daily multidisciplinary lunchtime meetings, allocate actions, and record them in patient records.
Verbatim wording from the response “Additionally, the daily lunchtime meeting at HMP Long Lartin is now properly minuted with actions being allocated and recorded in patient records. This meeting is attended by a range of staff and encourages greater discussion about the care of particular individuals. As a result of some of the issues raised in Mr Colton’s case, there have been changes to practices such as nurses undertaking pain scores. I am aware that individual nursing staff are more frequently recording pain scores in order to allow a judgment to be made as to whether a problem is persisting or becoming increasingly painful or resolving itself.” Source location 2015-0021-Response-by-Worcestershire-Health-Care-NHS
Open published response
8 Jan 2015 Eve Cullen · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 5 Failure to action received mental health referrals View source Lack of service-wide definitions for referral urgency levels View source Failure to treat clinically identified urgent referrals as urgent View source Failure to record a suggested timeframe for action on referrals View source Unstructured allocation of initial review timing to an individual psychiatrist View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Eve Cullen · 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
Eve Cullen, who had epileptic seizures and a fluctuating peri-ictal confusional state, went missing from her family home on 17 July 2014 and was later found dead in an alleyway on 9 August 2014. The concerns were that a hospital referral was not actioned, two urgent referrals were not treated as urgent, and there was no uniform definition or timeframe for urgent referrals.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to action received mental health referrals
Wider context from the report “(1) The failure to action the referral from the Queen Elizabeth Hospital
(2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent
(3) The lack of any uniform agreement as to what constitutes an 'urgent' referral
I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all . She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded.
She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way.
Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient.
I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of service-wide definitions for referral urgency levels
Wider context from the report “(1) The failure to action the referral from the Queen Elizabeth Hospital
(2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent
(3) The lack of any uniform agreement as to what constitutes an 'urgent' referral
I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine' ) and further when referrals are made no suggested timeframe is recorded.
She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way.
Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient.
I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to treat clinically identified urgent referrals as urgent
Wider context from the report “(1) The failure to action the referral from the Queen Elizabeth Hospital
(2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent
(3) The lack of any uniform agreement as to what constitutes an 'urgent' referral
I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded.
She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way.
Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient.
I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record a suggested timeframe for action on referrals
Wider context from the report “(1) The failure to action the referral from the Queen Elizabeth Hospital
(2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent
(3) The lack of any uniform agreement as to what constitutes an 'urgent' referral
I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded .
She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way.
Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient.
I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unstructured allocation of initial review timing to an individual psychiatrist
Wider context from the report “(1) The failure to action the referral from the Queen Elizabeth Hospital
(2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent
(3) The lack of any uniform agreement as to what constitutes an 'urgent' referral
I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded.
She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen , even though the psychiatrist would not have had any contact with a new patient referred in this way .
Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient.
I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.
Verbatim wording from the response “Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.
Verbatim wording from the response “Unfortunately, it has not to date been the case that the same process applies in respect of the other areas in which the Trust provides services in Worcestershire, however we are working with the North CCG’s to address this, as it is our ambition to introduce a standardised system across the County. The Trust is working towards performance measures for all categories of referrals and will incorporate into a policy, which will distinguish between urgent and routine referrals with defined timescales for contact.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-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 the standardised urgent-referral process in Wyre Forest.
Verbatim wording from the response “Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.
Verbatim wording from the response “I confirm that since receiving your correspondence the Trust has written to all general practitioners in Redditch & Bromsgrove on 4 February 2015 identifying a protocol for the referral of mental health patients and the timescales in which they can be seen. This clarifies that referrals marked urgent should be triaged within 24 hours. The triage process may involve a discussion with the referrer, a discussion with the individual and/or a face to face assessment.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The 4 July referral was received, and urgent follow-up was not initially indicated; it was scheduled for weekly multidisciplinary review.
Verbatim wording from the response “One issue that I do need to raise with you is in respect of the referral from the Queen Elizabeth Hospital dated 4 July 2014 which you did not believe had been actioned by the community mental health team. Having reviewed this matter, it was clarified that the referral dated 4 July 2014 was received by the community mental health team on 11 July 2014. Discussion with the Queen Elizabeth RAID (rapid assessment interface, discharge) confirmed that at the point of the referral urgent follow-up was not indicated, as a result the referral was due to be reviewed by the weekly multidisciplinary team meeting.” Source location 2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Open published response
17 Dec 2013 Sean Christopher Seabourne · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to provide timely face-to-face assessment of patients at high risk of concealed suicide View source Failure of effective communication of patient risk between mental health teams View source Failure to define and communicate mental health teams' roles and responsibilities for onward care View source Failure to formally document and disseminate referral concerns and requests View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sean Christopher Seabourne · 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
Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely face-to-face assessment of patients at high risk of concealed suicide
Wider context from the report “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself . There was no written confirmation of the CMHT duty workers view and requests.
(2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient.
(3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team.
It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself.
It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself.
Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of effective communication of patient risk between mental health teams
Wider context from the report “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests.
(2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient.
(3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team.
It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself.
It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself .
Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define and communicate mental health teams' roles and responsibilities for onward care
Wider context from the report “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests.
(2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient.
(3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team.
It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself.
It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself.
Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally document and disseminate referral concerns and requests
Wider context from the report “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests.
(2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient.
(3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team.
It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself.
It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself.
Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case.
” Open source report
16 Sep 2013 Reggie Johns · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 7 Failure to provide the ACCT document to the nurse during interview View source Failure to involve appropriately qualified healthcare personnel in reviews View source Lack of formal record keeping of communication between prisons View source Failure to hold required multidisciplinary review meetings View source Failure to record the nurse's professional view in the ACCT document View source Failure to ensure officers remain engaged throughout the review View source Failure to communicate constant watch status to relevant prison staff 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
Reggie Johns · 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
Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.
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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the ACCT document to the nurse during interview
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve appropriately qualified healthcare personnel in reviews
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare .
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review .
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal record keeping of communication between prisons
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff . Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold required multidisciplinary review meetings
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate .
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed .
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the nurse's professional view in the ACCT document
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view .
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers remain engaged throughout the review
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status.
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Herefordshire and Worcestershire Health and Care NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate constant watch status to relevant prison staff
Wider context from the report “(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status .
(2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate.
It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare.
This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review.
Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed.
(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view.
Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel.
Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents.
” 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 Prison Service Instruction 64/2011 to identify and address areas of non-compliance at HMP Hewell.
Verbatim wording from the response “I can also confirm that following the inquest into Mr Johns’ death ████████ and ████████ Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) – in order to identify any areas of non-compliance and to address these.” Source location 2013-0202-Response-by-Worcestershire-Health-Care-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 Disseminate and reiterate requirements for reviewing and documenting ACCT records for prisoners arriving at HMP Hewell.
Verbatim wording from the response “At the time of Mr Johns’ inquest when this issue was discussed, ████████ wrote to all staff within the healthcare team at HMP Hewell to set out their expectations in respect of prisoners arriving in Reception at HMP Hewell on an ACCT. These are as follows:” Source location 2013-0202-Response-by-Worcestershire-Health-Care-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 Ensure appropriate information is communicated to receiving prisons when prisoners transfer from Trust-supported prisons.
Verbatim wording from the response “Messrs ████████ and ████████ will ensure that appropriate information is communicated to receiving prisons” Source location 2013-0202-Response-by-Worcestershire-Health-Care-NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing healthcare representation in relevant ACCT reviews is considered sufficient to address concerns about healthcare involvement.
Verbatim wording from the response “Healthcare provides representation into Assessment, Care in Custody and Teamwork (ACCT) reviews as follows:” Source location 2013-0202-Response-by-Worcestershire-Health-Care-NHS
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 Established ACCT reception review and recording requirements are considered sufficient to address concerns about identifying and managing prisoner risk.
Verbatim wording from the response “At the time of Mr Johns’ inquest when this issue was discussed, ████████ wrote to all staff within the healthcare team at HMP Hewell to set out their expectations in respect of prisoners arriving in Reception at HMP Hewell on an ACCT. These are as follows:” Source location 2013-0202-Response-by-Worcestershire-Health-Care-NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing healthcare, discipline-team and prison-transfer communication arrangements are considered sufficient to address information-sharing concerns.
Verbatim wording from the response “Whilst this concern largely focuses on the issue of communication between HMP Bristol and HMP Hewell I think it is appropriate to seek to reassure you about communication between the healthcare team at HMP Hewell and other HM Prisons. There is continuous dialogue within HMP Hewell between the healthcare and the discipline teams. Some of this is formalised through various meetings and forums and some is informal and reflects a relatively constant ebb and flow of communication on patient specific issues, task related discussion, operational issues and joint working. If prisoners are transferring to other prisons the prisoner’s healthcare record is transferred to the receiving prison. In some cases the Nurse in Reception at HMP Hewell will contact the receiving prison to raise specific issues or concerns.” Source location 2013-0202-Response-by-Worcestershire-Health-Care-NHS
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations