Horsham District Council

Local government · English district council

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First report 15 Mar 2021•Latest report 15 Mar 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: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Horsham District Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Mar2021
West Sussex
Concerns raised11
1. Failure to include and inform the primary support practitioner in discharge arrangements
2. Lack of mechanism to notify service users when lead practitioners are unavailable
3. Failure to inform family supporters of discharge
1. Failure to assign responsibility for risk management and crisis referral
2. Inadequate assessment and recording of service-user risk
3. Failure to notify vulnerable service users’ parents of discharge
4. Failure to provide safe and therapeutic post-discharge accommodation
5. Inadequate recording of deterioration in mental health presentation
6. Lack of staff understanding of actions required after Red Zone placement
7. Provision of accommodation that is not a safe and therapeutic environment
8. Failure to include and alert the primary lead practitioner in discharge arrangements
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

James Kenneth Herbertson · 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 Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.

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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to include and inform the primary support practitioner in discharge arrangements
Wider context from the report
“a) The discharge arrangements from Langley Green Hospital did not include the Lead Practitioner who was going to be the primary contact responsible for providing the support to James following discharge. Although she had met him once no therapeutic relationship had been established and at the point of discharge, she was not aware that discharge had taken place. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of mechanism to notify service users when lead practitioners are unavailable
Wider context from the report
“a) The use of Text messaging is a good way of communicating between the Trust staff and a Service User particularly when they require assistance. However, Service users can place a reliance on this method of communication. It is therefore unfortunate that there is no mechanism to notify a service user that their lead practitioner is unavailable (due to leave or other work commitments) to deal with their message. Technology may not currently provide for an automatic “unavailability” response however this does leave service users vulnerable if they are in need of urgent help. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to inform family supporters of discharge
Wider context from the report
“b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to assign responsibility for risk management and crisis referral
Wider context from the report
“c) His lead practitioner was not available at the time and nobody appears to have taken responsibility to manage James’ risk or make a referral to the crisis team. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Inadequate assessment and recording of service-user risk
Wider context from the report
“b) James’ risk was not adequately accessed or recorded in his medical records following him being placed in the “Red Zone”. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to notify vulnerable service users’ parents of discharge
Wider context from the report
“b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide safe and therapeutic post-discharge accommodation
Wider context from the report
“c) The accommodation offered to James both on leaving hospital (and subsequently) was not a safe and therapeutic environment for a person who had recognised mental health difficulties with a history of alcohol and substance misuse. Whilst accommodation is a matter for the Local Authority the Trust staff work with partner agencies in the planning for a S17 discharge. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Inadequate recording of deterioration in mental health presentation
Wider context from the report
“a) It was clear that James’ Mental health was deteriorating on the visit by the lead practitioner on 8th April 2019. This change in presentation was discussed at the Multidisciplinary meeting on 9th April 2019 but was not adequately recorded. He was placed in “Red Zone”. It was clear from the evidence that there was a lack of understanding by individual staff as to what actions they should be taking following a service user being placed in “Red Zone”. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff understanding of actions required after Red Zone placement
Wider context from the report
“a) It was clear that James’ Mental health was deteriorating on the visit by the lead practitioner on 8th April 2019. This change in presentation was discussed at the Multidisciplinary meeting on 9th April 2019 but was not adequately recorded. He was placed in “Red Zone”. It was clear from the evidence that there was a lack of understanding by individual staff as to what actions they should be taking following a service user being placed in “Red Zone”. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Provision of accommodation that is not a safe and therapeutic environment
Wider context from the report
“c) The accommodation offered to James both on leaving hospital (and subsequently) was not a safe and therapeutic environment for a person who had recognised mental health difficulties with a history of alcohol and substance misuse. Whilst accommodation is a matter for the Local Authority the Trust staff work with partner agencies in the planning for a S117 discharge. ”
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 Horsham District Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to include and alert the primary lead practitioner in discharge arrangements
Wider context from the report
“a) The discharge arrangements from Langley Green Hospital did not include the Lead Practitioner who was going to be the primary contact responsible for providing the support to James following discharge. Although she had met him once no therapeutic relationship had been established and at the point of discharge, she was not aware that discharge had taken place. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised11

Failure to include and inform the primary support practitioner in discharge arrangements

Lack of mechanism to notify service users when lead practitioners are unavailable

Failure to inform family supporters of discharge

Failure to assign responsibility for risk management and crisis referral

Inadequate assessment and recording of service-user risk

Failure to notify vulnerable service users’ parents of discharge

Failure to provide safe and therapeutic post-discharge accommodation

Inadequate recording of deterioration in mental health presentation

Lack of staff understanding of actions required after Red Zone placement

Provision of accommodation that is not a safe and therapeutic environment

Failure to include and alert the primary lead practitioner in discharge arrangements