15 Mar 2021 James Kenneth Herbertson · Prevention of Future Deaths report West Sussex
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Concerns raised 11 Failure to include and inform the primary support practitioner in discharge arrangements View source Lack of mechanism to notify service users when lead practitioners are unavailable View source Failure to inform family supporters of discharge View source Failure to assign responsibility for risk management and crisis referral View source Inadequate assessment and recording of service-user risk View source Failure to notify vulnerable service users’ parents of discharge View source Failure to provide safe and therapeutic post-discharge accommodation View source Inadequate recording of deterioration in mental health presentation View source Lack of staff understanding of actions required after Red Zone placement View source Provision of accommodation that is not a safe and therapeutic environment View source Failure to include and alert the primary lead practitioner in discharge arrangements View source See 8 more concerns
Responses linked to these concerns
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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.
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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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations