10 Jan 2025 Eden Anna Street · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1 Failure to feed back telephone helpline information about autistic children to the weekly audit meeting and clinical priority decision-makers View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Require increased-risk contacts handled by duty workers to be discussed within three working days at the next waiting-list or multidisciplinary team meeting.
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Action
Introduce a duty-team risk review form capturing waiting-list calls, information received, actions, and clinical rationale for meeting-based review.
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Action
Include checks of risk review form use in future record-keeping audits.
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AI-generated summary
Eden Anna Street · 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
Eden Anna Street, aged 13, was found suspended by her sister and could not be revived; she was declared deceased on 27 June 2021. The report describes concerns that information provided by parents of autistic children through a Trust telephone helpline was not fed back to the Trust’s weekly audit meeting, meaning potentially worsening information might not reach those able to alter clinical priorities.
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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 Humber Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to feed back telephone helpline information about autistic children to the weekly audit meeting and clinical priority decision-makers
Wider context from the report “Whereas the Humber Teaching NHS Foundation Trust has implemented a number of measures following the publication of a Serious Incident Investigation Report in light of admitted failings, evidence was heard that information provided by parents of autistic children via a telephone helpline operated by the Trust, is not fed back to the weekly audit meeting convened by the Trust . As a result, information about children with neurodiversity issues that might have altered for the worse, may not be available to those who can alter their clinical priorities .
” 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 Require increased-risk contacts handled by duty workers to be discussed within three working days at the next waiting-list or multidisciplinary team meeting.
Verbatim wording from the response “An additional safeguard is that where contact about a young person has been received and dealt with as above by the duty worker, then where there is an increase in risk (e.g. expressions of suicidality of any degree, or a change in known risk profile, no matter what the outcome of that contact, the contact is referenced within a clinical discussion within three working days at the weekly waiting list or weekly MDT meeting (whichever is next due to take place). This gives an opportunity for any further input into the information and decision-making to be provided by the broader professional group. This would include cases where the outcome of the contact is that there will be no change to clinical prioritisation, and this gives an opportunity for this decision to be “double checked” by the wider group and safeguarding responses provided if required.” Source location Response from Humber Teaching NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a duty-team risk review form capturing waiting-list calls, information received, actions, and clinical rationale for meeting-based review.
Verbatim wording from the response “Additionally, the Trust is implementing a new electronic record keeping system and as part of that, is introducing a risk review form for use by the duty team which will capture calls made to the service. The form will outline the nature of the call and the information provided, and the agreed actions with the supporting clinical rationale. This form will be used as the basis for review of such contacts in the weekly waiting list or weekly MDT meetings. (The use of these forms is just being introduced now with the new electronic system and in the future record keeping audits will include checks to see they are being utilised.)” Source location Response from Humber Teaching NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include checks of risk review form use in future record-keeping audits.
Verbatim wording from the response “Additionally, the Trust is implementing a new electronic record keeping system and as part of that, is introducing a risk review form for use by the duty team which will capture calls made to the service. The form will outline the nature of the call and the information provided, and the agreed actions with the supporting clinical rationale. This form will be used as the basis for review of such contacts in the weekly waiting list or weekly MDT meetings. (The use of these forms is just being introduced now with the new electronic system and in the future record keeping audits will include checks to see they are being utilised.)” Source location Response from Humber Teaching NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that the reported case involved its services or provides evidence of a systemic issue affecting CAMHS waiting-list contacts.
Verbatim wording from the response “The Trust made further enquiries via those representing Eden’s family and sought detail of the case that had been referred to during the Inquest, which we understand was the basis for the PFD report. Helpful information was forthcoming including the name of the child, which enabled the Trust to review that matter. It transpires that child was not and is not on the Trust’s Core CAMHS waiting list and the circumstances pertaining to that child do not in any way relate to the substantive issue raised within the PFD report.” Source location Response from Humber Teaching NHS Foundation Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations