Hertfordshire Partnership University NHS Foundation Trust

Health and care · NHS trust

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First report 19 Aug 2016•Latest report 29 Jun 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
11

Described in responses

Concerns and recipient responses

Statements from Hertfordshire Partnership University NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Hertfordshire

    AI-generated summary

    Katie Louisa Locke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Katie Louisa Locke was unlawfully killed at Theobalds Park Hotel on 24 December 2015 by forceful and prolonged compression of her neck, accompanied by serious sexual violence. The report identifies concerns about gaps in information held by public bodies, insufficient information-sharing, and inadequate dissemination and understanding of the potentially dangerous persons process, creating a continuing risk that it may not be properly used to protect the public.

    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 Hertfordshire Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient dissemination and understanding of the PDP process across agencies

    Wider context from the report

    “Evidence in the Inquest revealed that, whilst the two police forces who dealt with the murderer both had a PDP process in place, however, the existence of the process and its operation was not known and understood by everyone working at all levels in the police. Furthermore, whilst all other relevant public agencies should have had an awareness of the PDP process and how to make contact via the Police, it seems that knowledge of the PDP process amongst those staff of the Hertfordshire Partnership NHS Foundation Trust and Hertfordshire Probation Service who gave evidence at the inquest was sporadic. It is not possible for me to know whether this is a fair reflection of the broader understanding and engagement in the PDP process by the respective organisations. Nevertheless, it gives rise to the concern that information about the PDP process is not sufficiently well disseminated throughout all of the agencies who need to work together within the PDP process to make it work and that further training and/or exchange of information may be helpful. I consider that unless some action is taken there is a continuing risk that the PDP process will not be properly used to achieve its purpose and provide protection to the public from potentially dangerous people. ”
    Open source report

  2. City of London

    AI-generated summary

    Nathan Anthony Lowe · 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

    Nathan Anthony Lowe was discharged from hospital and a Section 2 Mental Health Act Order in October 2015, with community psychiatric follow-up arranged. He fell to his death in central London on 12 May 2016; the concern was whether more should have been done to contact him between 10 March and 12 May given his illness and non-compliance with follow-up.

    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 Hertfordshire Partnership University NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient contact with a patient who is non-compliant with follow-up

    Wider context from the report

    “Whether or not more should have been done to make contact with the patient between the 10th March and 12th May given the nature of his illness and the fact of his non-compliance with follow up. Such consideration is relevant to a Coroner’s duty in connection with the prevention of future deaths ”
    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

    Record clear actions, deadlines and responsible leads from multidisciplinary meetings in meeting notes and electronic service-user records.

    Verbatim wording from the response

    “3. Clear actions and timeframes by when these actions will be completed and by whom, are now more clearly recorded in the notes of each MDT meeting. These actions and associated timeframes and leads are also recorded in the service users’ electronic record.”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen team leadership and oversight of follow-up and multidisciplinary decision-making for service users with complex needs.

    Verbatim wording from the response

    “I am aware that immediately following completion of the serious incident report the Service Line Lead responsible for this Quadrant met with the North West Adult community team members to discuss the learning and take the opportunity to personally review existing processes to look at ways in which the multi-disciplinary ways of working could be strengthened. The following actions have been taken since that time:”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review care-coordinator caseloads to identify further actions required.

    Verbatim wording from the response

    “5. A review of the care coordinators case load is being undertaken to identify if there are any further areas where actions may need to be taken”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    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

    Pilot a clinical zoning tool in two community teams to identify high-risk service users requiring increased monitoring and intervention.

    Verbatim wording from the response

    “6. A clinical zoning tool is being piloted in two community teams including the North West. Through training this will assist in identifying those service users in each of the community teams who have high risk factors that require increased monitoring and interventions by the multi-disciplinary members of the clinical team.”

    Source location

    Nathan-Lowe-Response
    Page 2 · response
    Published 19 August 2016

    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

Data last updated 7 September 2026