2 Feb 2026 David ROOMES · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 4 Delays and inadequate triage of referrals View source Failure to ensure complex risk assessments are undertaken by qualified clinicians View source Inadequate training and understanding among non-clinical decision makers View source Delays and missed opportunities in referral to qualified clinicians 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.
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AI-generated summary
David ROOMES · 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
David ROOMES, who had bipolar affective disorder and a relapse in depressive symptoms, was found deceased in the garage of his address on 14 April 2025, having suspended himself by ligature. The concerns included delays and shortcomings in referral triage, the absence of assessment by a qualified clinician, delays and missed opportunities for clinical review, and potential wider training issues for non-clinical decision makers.
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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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and inadequate triage of referrals
Wider context from the report “(1) There was a significant delay in David's referral to the Trust being triaged. When the triage did take place, I was told in evidence that David's referral was not triaged well , which had numerous implications for David's treatment later on. I was told that the Trust now provides more support for staff triaging referrals; however, this did not provide sufficient reassurance that the risks have been addressed. I am also mindful of Prevention of Future Death report (2026-0023), written by me on 12 January 2026, which contained a similar concern about the process for triaging referrals (albeit in relation to a different team within the Trust). This indicates that this may not be a localised, team specific, issue in terms of the triaging of referrals .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure complex risk assessments are undertaken by qualified clinicians
Wider context from the report “(2) David's Dialog+ assessment (an assessment tool, which includes questions to assess risk) was not undertaken by a clinician. I was told in evidence that, given the complexities of David's case, his Dialog+ assessment 'would have benefitted' from assessment by a clinician and that he should have been seen by a qualified clinician at that appointment .
I heard evidence that the Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it. However, that plan did not include referral to be seen and assessed by a qualified clinician, whereas the evidence I heard was that there was an expectation that David should have been referred to a qualified clinician.
While I heard and accepted the evidence that a patient in a similar situation to David would now be able to access the MHT+ team directly, the issue here is one of potential training concerns where non-clinical decision makers are potentially over-confident or may not fully understand the nature and effect of the decisions they are required to make. I was not reassured that this matter has been addressed.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and understanding among non-clinical decision makers
Wider context from the report “(2) David's Dialog+ assessment (an assessment tool, which includes questions to assess risk) was not undertaken by a clinician. I was told in evidence that, given the complexities of David's case, his Dialog+ assessment 'would have benefitted' from assessment by a clinician and that he should have been seen by a qualified clinician at that appointment.
I heard evidence that the Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it. However, that plan did not include referral to be seen and assessed by a qualified clinician, whereas the evidence I heard was that there was an expectation that David should have been referred to a qualified clinician .
While I heard and accepted the evidence that a patient in a similar situation to David would now be able to access the MHT+ team directly, the issue here is one of potential training concerns where non-clinical decision makers are potentially over-confident or may not fully understand the nature and effect of the decisions they are required to make . I was not reassured that this matter has been addressed.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and missed opportunities in referral to qualified clinicians
Wider context from the report “(3) It was accepted in evidence that there was a delay in David being seen by a qualified clinician . It was further accepted that there were numerous 'missed opportunities' for David to be referred to, or seen / spoken to by, a qualified clinician . Again, I accept that a similar patient now, would be able to access the MHT+ team directly. However, the concern remains that there is potentially a wider training issue that could lead to continued 'missed opportunity' exposing future patients to continued risks.
” Open source report
14 Jan 2026 Stephen Taylor · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 5 Failure to assign ownership of urgent risk management across services View source Failure to integrate significant indicators of elevated suicide risk into clinical decision-making View source Failure to act on family-provided information indicating heightened and escalating risk View source Delays in actioning necessary referrals to secondary mental health services View source Failure to coordinate real-time escalation across services 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
Stephen Taylor · 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 Taylor experienced worsening mental distress linked to work and financial concerns, with escalating risk indicators and repeated contact with health services. He died on 26 May 2025 after deliberately jumping from Louisa Bay Cliffs. The principal concerns were the lack of coordinated escalation and ownership of risk across services, reliance on his denial of immediate intent despite other risk indicators, routine rather than urgent referrals, and the absence of a same-day urgent face-to-face assessment despite family concerns.
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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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign ownership of urgent risk management across services
Wider context from the report “(5) Responsibility for escalation became diffuse across multiple services , creating a foreseeable risk that no single service took ownership of urgent risk management .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate significant indicators of elevated suicide risk into clinical decision-making
Wider context from the report “(2) Clinical decision-making consistently relied on Mr Taylor’s denial of immediate intent and his stated ability to keep himself safe , despite significant indicators of elevated risk , including a previous serious suicide attempt, escalating distress, severe anxiety, sleep disturbance, reduced self-care, and repeated concerns raised by a close family member.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on family-provided information indicating heightened and escalating risk
Wider context from the report “(4) Family-provided information indicating heightened and escalating risk did not result in same-day escalation or urgent face-to-face clinical assessment .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in actioning necessary referrals to secondary mental health services
Wider context from the report “(3) Referrals to secondary mental health services were identified as necessary by more than one service but were treated as routine rather than urgent , and were not actioned immediately .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate real-time escalation across services
Wider context from the report “(1) Mr Taylor was in contact with multiple services during a period of escalating mental distress. Each service operated within its own framework, but there was no evidence of coordinated, real-time escalation or ownership of risk across services.
” 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 Update Urgent Mental Health Helpline training expectations for CRAM through the revised Standard Operating Procedure.
Verbatim wording from the response “The Urgent Mental Health Helpline Standard Operating Procedure has undergone thorough review which has resulted in an update to:” Source location Response from Kent and Medway mental Health 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 Train staff in the appropriate pathway and method for requesting an emergency Police response under Right Care Right Person.
Verbatim wording from the response “• update to the ‘immediate risk to life’ response under Right Care Right Person. Staff are being trained to understand the appropriate pathway and method to request this emergency Police response.” Source location Response from Kent and Medway mental Health 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 Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Verbatim wording from the response “As a result of this very sad death, the Urgent Mental Health Helpline, has generated visual prompts at each call station to support clear identification and pathways for call handlers/clinicians to direct, where risk is of concern, a referral for a rapid assessment within 4 hours by our Rapid Response service. It is expected that our staff will not rely on a risk prompt tool but will be equipped to identify risk accurately and utilise a curious approach to seeking further risk information, from the patient, their families and referrers.” Source location Response from Kent and Medway mental Health 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 Reduce the target timeframe for triaging urgent referrals from 72 hours to 24 hours.
Verbatim wording from the response “The Urgent Mental Health Helpline Standard Operating Procedure has undergone thorough review which has resulted in an update to:” Source location Response from Kent and Medway mental Health 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 Define high-risk patient categories and relevant risk-factor demographics in the revised Standard Operating Procedure.
Verbatim wording from the response “The Urgent Mental Health Helpline Standard Operating Procedure has undergone thorough review which has resulted in an update to:” Source location Response from Kent and Medway mental Health 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 Deliver a two-day CRAM training event for Urgent Mental Health Helpline staff to improve risk recognition, risk curiosity and co-produced care and risk management planning.
Verbatim wording from the response “With regard to improving risk recognition within the Kent & Medway Urgent Mental Health Helpline, the staff from this service are undergoing a 2-day Clinical Risk Assessment & Management (CRAM) training event to support improved risk recognition and risk curiosity, and to promote deeper questioning of patients who present with elevated risks and/or risk factors. This will include a focus on creation of a co-produced care and risk management plan.” Source location Response from Kent and Medway mental Health 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 Facilitate a phased training and support package with NHS Talking Therapies Collaborative to improve referral matching and risk communication.
Verbatim wording from the response “KMMH and NHS Talking Therapies Collaborative are currently in discussion facilitating a phased training and support package to mutually ensure patients are placed with the best service provider to meet needs of patients at point of referral.” Source location Response from Kent and Medway mental Health 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 Require staff to review practicably accessible clinical records during triage, including CRAM risk event logs.
Verbatim wording from the response “The Urgent Mental Health Helpline Standard Operating Procedure has undergone thorough review which has resulted in an update to:” Source location Response from Kent and Medway mental Health NHS Trust
Open published response
11 Jan 2026 Mark Stuart VIDLER · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 10 Pre-determined HTT discharge decisions before patient assessment View source Lack of clear senior clinical oversight and decision-making accountability for Rapid Response Team referrals View source Unavailability of CAMS integration with the computerised records system View source Lack of dedicated resource to manage or support CAMS implementation View source Limited out-of-hours availability of MHT+ support for Rapid Response Team referrals View source Failure of HTT clinicians to recognise the extent of documented risk factors View source Lack of care co-ordinators View source Failure to provide patient-centred care View source Failure to include the receiving MHT+ team in HTT discharge decisions View source Lack of safety-netting for the use of paper and computerised records View source See 7 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
Mark Stuart VIDLER · 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
Mark Vidler had severe depression and was receiving mental health care from Kent and Medway Mental Health NHS Trust. After serious suicide attempts on 30 April and 7 May 2025, he was discharged from the Home Treatment Team and was not reviewed by an out-of-hours clinician on the night of 7 May after a Rapid Response Team referral was declined. He was found dead at home on 8 May 2025, and the inquest concluded that his suicide was contributed to by a failure in care. Concerns included shortcomings in patient-centred care, clinical oversight and referral processes, risk recognition, discharge decision-making, continuity of care, care coordination, and the implementation and recording of suicidality management.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Pre-determined HTT discharge decisions before patient assessment
Wider context from the report “(4) I heard evidence that the decision to discharge Mark from the HTT was made at a multi-disciplinary team (MDT) meeting prior to the HTT nurse visiting Mark on 6 May 2025. This raises the concern that the decision was pre-determined . I heard no evidence that this situation has changed .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear senior clinical oversight and decision-making accountability for Rapid Response Team referrals
Wider context from the report “(2) The process in place for triaging and considering referrals to the Rapid Response Team is reliant, for the most part, on call handlers working through a script and there is a total lack of clarity regarding clinical decision making in this regard. The Trust acknowledged in its PSII report that there was "no evidence of senior clinical oversight of the decision making or clarity as to where the final clinical decision sits regarding accepting or declining referrals ". A senior manger from the Trust told me, in evidence, that there is still work to be done to address this concern .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of CAMS integration with the computerised records system
Wider context from the report “(7) The Collaborative Assessment and Management of Suicidality (CAMS) work undertaken by the Trust lacks "dedicated resource in place to manage or support implementation" (quote taken from Trust PSII report). I also heard that the CAMS programme cannot currently be integrated with the Trust's computerised records system , due to copyright issues. This matter was due to be resolved by June 2025; however, it remains unresolved with a current target date of June 2026 . I was told that there is no system in place to safety net the use of both paper and computerised records in the meantime.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of dedicated resource to manage or support CAMS implementation
Wider context from the report “(7) The Collaborative Assessment and Management of Suicidality (CAMS) work undertaken by the Trust lacks "dedicated resource in place to manage or support implementation" (quote taken from Trust PSII report). I also heard that the CAMS programme cannot currently be integrated with the Trust's computerised records system, due to copyright issues. This matter was due to be resolved by June 2025; however, it remains unresolved with a current target date of June 2026. I was told that there is no system in place to safety net the use of both paper and computerised records in the meantime.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited out-of-hours availability of MHT+ support for Rapid Response Team referrals
Wider context from the report “(8) I heard evidence that as a result of the referral to the Rapid Response Team being declined, Mark's mental health care technically rested with the MHT+ team, which only works until 17:00 . As a result, the Approved Mental Health Practitioner service (responsible for arranging MHA assessments) would have been unable to speak to the referrer. While this was not an issue in the specific circumstances of this case, I consider that it raises risks for others 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of HTT clinicians to recognise the extent of documented risk factors
Wider context from the report “(3) Evidence I considered showed that some risk factors, such as the masking of symptoms, were well documented. However, the HTT clinician still appeared not to acknowledge the extent of such risks . This raises the risk of a repeat of this concern 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of care co-ordinators
Wider context from the report “(6) I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patient-centred care
Wider context from the report “(1) Some staff at the Trust were so focused on 'process' that they lost sight of the need for patient centred care . This was accepted within the Trusts PSII report. I was insufficiently reassured that action has been taken to address this matter .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include the receiving MHT+ team in HTT discharge decisions
Wider context from the report “(5) Both the nurse from MHT+ and the consultant psychiatrist gave evidence that the MHT+ were not included, as the receiving team, in the MDT decision on 6 May 2025. They considered that this could have been useful and is something that can and has happened in the past. I was told that this left Mark 'in limbo' following the his discharge from HTT and I was told that this is something that has not changed since .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of safety-netting for the use of paper and computerised records
Wider context from the report “(7) The Collaborative Assessment and Management of Suicidality (CAMS) work undertaken by the Trust lacks "dedicated resource in place to manage or support implementation" (quote taken from Trust PSII report). I also heard that the CAMS programme cannot currently be integrated with the Trust's computerised records system, due to copyright issues. This matter was due to be resolved by June 2025; however, it remains unresolved with a current target date of June 2026. I was told that there is no system in place to safety net the use of both paper and computerised records in the meantime .
” 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 Provide senior Rapid Response clinical input to interface forums for clinically considered decisions and agreed safe discharge plans.
Verbatim wording from the response “The Rapid Response Team will have senior clinical input into these interface forums where decisions impacting on patient care can be discussed and decisions made clinically to ensure the person has an agreed discharge plan that promotes clinical safety and is based on senior clinical consideration. The revised Standard Operating Procedure will detail that MHT+ colleagues including medics must be invited to these forums to assist with community treatment planning and will be audited 3 monthly to ensure quality, patient safety and positive patient outcomes agreed across the interface of services.” Source location Response from Kent and Medway NHS Mental Health 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 named worker within the refined community model of care.
Verbatim wording from the response “6. I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising in the future.
The Trust has and is undergoing transformation in line with the Community Mental Health Framework (CMHF) which includes a national directive to move away from care co-ordination. As part of our continuous improvement agenda and refinement of the community model of care the Trust has identified a number of service improvement which we will be making and which will include the introduction of a named worker.” Source location Response from Kent and Medway NHS Mental Health 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 Deliver dedicated CRAM training for Home Treatment and Rapid Response staff on risk questions, protective factors, masking symptoms, and collaboratively written care plans.
Verbatim wording from the response “The revision of the Trust wide Home Treatment Team and Rapid Response Standard Operating Procedure review which is currently underway, is due for completion by 1 April 2026. In addition; to the revision of the SOP’s both the Home Treatment and Rapid Response Teams are booked to undertake CRAM training for both qualified and unqualified staff. This will be completed by April 2026. This training will specifically address the need for clinicians to be curious and ask specific risk questions around safety and protective factors as well as co-written plans of care in conjunction with carers and family where to do so. This will ensure person centred care is at the centre of all assessments.” Source location Response from Kent and Medway NHS Mental Health 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 Implement Trust-wide quality audits and weekly tracking of CRAM documentation to improve risk recognition and safety planning.
Verbatim wording from the response “The Trust has implemented quality audits to determine the quality of the Risk Assessment & Management plans across the Trust, and as such there is an ongoing Trust wide quality improvement drive to establish improvements particularly around risk recognition and safety planning. As part of this work, there is weekly tracking of our improvement trajectory targets for completion of the CRAM documents.” Source location Response from Kent and Medway NHS Mental Health 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 a six-month Band 7 clinician secondment to support CAMS practice and CRAM training.
Verbatim wording from the response “The Trust are currently considering options in relation to a dedicated workforce of CAMS trained workers across our services. In addition, the continued roll out of this specialist service is under review by the organisation. This will inform the finalised CAMS Standard Operating Procedure. In the meantime, a 6-month secondment role has been agreed to support the CAMS service (band 7 clinician). This role is split equally between CAMS practice and training staff in CRAM.” Source location Response from Kent and Medway NHS Mental Health 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 Hold twice-weekly multidisciplinary discussions with community services about patient care, including planned Home Treatment Team discharges.
Verbatim wording from the response “The HTT have initiated a twice weekly MDT discussions with Community services which focuses discussion on aspects of individual patients care including those patients for whom discharge is planned from HTT. This allows for the wider support system to debate and consider the decision to discharge.
In addition, as part of the Trusts ongoing development, of understanding and managing risk with our patients, a risk assessment is completed at discharge. If the clinician completing the risk assessment identifies a deterioration in mental state this can and should delay that decision- the team have a mechanism for discussion and decision making regarding clinical care, on a daily basis, and access to a Consultant Psychiatrist for advice and guidance in complex cases.” Source location Response from Kent and Medway NHS Mental Health 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 Hold twice-weekly clinical interface meetings with local MHT and MHT+ teams to discuss specific cases and support timely community treatment planning.
Verbatim wording from the response “Following this Inquest outcome, the Home Treatment Team service have implemented a twice weekly clinical MDT interface meeting with local MHT and MHT+ teams to enable and ensure timely discussion of specific cases. Feedback from the clinical teams has been positive as these forums are the opportunity to discuss patients of concern where risk continues to be identified.” Source location Response from Kent and Medway NHS Mental Health 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 Revise procedures to require invitations to MHT+ colleagues, including medics, and audit forum participation quarterly for quality and patient safety.
Verbatim wording from the response “The Rapid Response Team will have senior clinical input into these interface forums where decisions impacting on patient care can be discussed and decisions made clinically to ensure the person has an agreed discharge plan that promotes clinical safety and is based on senior clinical consideration. The revised Standard Operating Procedure will detail that MHT+ colleagues including medics must be invited to these forums to assist with community treatment planning and will be audited 3 monthly to ensure quality, patient safety and positive patient outcomes agreed across the interface of services.” Source location Response from Kent and Medway NHS Mental Health 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 Revise the Trust-wide Home Treatment and Rapid Response procedures to require senior clinical oversight before declining referrals and agreement of alternative care.
Verbatim wording from the response “The Trust wide Rapid Response Standard Operating Procedure is being revised and amended to ensure referrals received are accepted by call handlers. No referral will be declined until a senior clinician has had oversight, and alternative care agreed. As such each referral will be reviewed by a Rapid Response clinician in collaboration with the referring clinician, thereby ensuring decision making is person centred.” Source location Response from Kent and Medway NHS Mental Health 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 Care coordinators will not be introduced because the national Community Mental Health Framework directs services to move away from care coordination.
Verbatim wording from the response “6. I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising in the future.
The Trust has and is undergoing transformation in line with the Community Mental Health Framework (CMHF) which includes a national directive to move away from care co-ordination. As part of our continuous improvement agenda and refinement of the community model of care the Trust has identified a number of service improvement which we will be making and which will include the introduction of a named worker.” Source location Response from Kent and Medway NHS Mental Health Trust
Open published response
9 Jan 2026 Sarah Heaver · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 4 Failure to undertake structured neurological observations View source Failure to undertake appropriate neurological investigation View source Unavailability of psychiatric input after acute hospital discharge View source Inconsistent, unreliable and incomplete medical records View source See 1 more concern
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
Sarah Heaver · 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
Sarah Heaver, aged 59, was found unconscious at home on 21 May 2024 and later entered the sea at Whitstable in a deliberate attempt to end her life; she was pronounced deceased in hospital on 27 May 2024. Concerns included the absence of a CT head scan and structured neurological observations after presentation with a very low GCS, inconsistent and incomplete medical records, and gaps in access to psychiatric input after discharge from acute hospital care.
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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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake structured neurological observations
Wider context from the report “(2) I am concerned that no structured neurological observations were undertaken on a patient presenting with such a low GCS, risking deterioration being 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake appropriate neurological investigation
Wider context from the report “(1) Sarah Heaver was admitted with a GCS of 3, later improving to between 5–8/15, with unknown downtime and an unclear history. A CT head scan was indicated and not undertaken. I am concerned that appropriate neurological investigation was not carried out .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of psychiatric input after acute hospital discharge
Wider context from the report “(4) I am concerned that patients are discharged from acute hospital settings on the understanding that they will receive psychiatric input equivalent to hospital admission, only for it to later become apparent that there is no access to a psychiatrist or prescriber for several days , particularly over bank holiday periods .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent, unreliable and incomplete medical records
Wider context from the report “(3) Throughout this investigation I was presented with inconsistent, unreliable and incomplete medical records . This significantly hindered my ability to investigate the death and creates a risk of future patient harm.
” 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 Provide prescribing cross-cover through a three-prescriber rolling rota for weekends, bank holidays, annual leave and sickness.
Verbatim wording from the response “At the time of the inquest of Mrs Heaver, the Trust had already identified that there was a lack of consistent cover provided for prescribing over weekends. This was identified by the Service Manager in February 2025, when it became apparent that all 3 Independent prescribers were on annual leave at the same time. This had unfortunately occurred due to 2 of the 3 undertaking additional training at university and they had not been able to utilise their leave in line with Trust policy. As a trust we will ensure this situation does not arise again. At the time of identifying this shortfall in regards to appropriate prescribing cover, in consultation with the three independent prescribers and ████████, Consultant Psychiatrist, it was agreed that there would be a change in working pattern for the three independent prescribers subsequently working on a three-week rolling rota.” Source location Response from Kent and Medway Mental Health 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 Transfer responsibility for booking and agreeing prescribers’ annual leave to Operational Team Managers.
Verbatim wording from the response “The responsibility for appropriate booking and agreement of annual leave was also transferred from the medical staff and was added to the rostering responsibility of the Operational Team Managers. This has now become established practice. All 3 prescribers now provide cross cover for both teams on all weekends, bank holidays, annual leave or sickness and this is reviewed in the teams total staffing cover weekly by the Operational Team managers. It has been agreed that if required, NHS Professionals can be utilised to provide prescribing cover, if the need should arise.” Source location Response from Kent and Medway Mental Health 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 Review total prescribing staffing cover weekly through the Operational Team Managers.
Verbatim wording from the response “The responsibility for appropriate booking and agreement of annual leave was also transferred from the medical staff and was added to the rostering responsibility of the Operational Team Managers. This has now become established practice. All 3 prescribers now provide cross cover for both teams on all weekends, bank holidays, annual leave or sickness and this is reviewed in the teams total staffing cover weekly by the Operational Team managers. It has been agreed that if required, NHS Professionals can be utilised to provide prescribing cover, if the need should arise.” Source location Response from Kent and Medway Mental Health NHS Trust
Open published response
4 Mar 2024 Sarah Rhiannon Keen · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Failure to provide carers with relevant patient risks and care information View source Failure to document and communicate discharge medication recommendations View source Use of clinical abbreviations not universally understood by the medical team 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
Sarah Rhiannon Keen · 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
Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide carers with relevant patient risks and care information
Wider context from the report “(1) The enhanced carer had not been told the reason that she was providing one to one care for Sarah, was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that Sarah was a risk of deliberate self harm including by overdosing on prescribed medications. She was not aware that Sarah had been discharged with seven days of medication or that her medication was being held on her behalf by another in the community. Although it was unusual for her to accompany a person with capacity to their address it was not unusual for her to accompany those without capacity. As a consequence the support worker who was on duty at the time that Sarah returned to her accommodation was not aware from an independent source that Sarah had been discharged with seven days of medication, Sarah lied to the support worker when she was asked whether she had been given any medication disclosing only the fact that she had been given ferrous sulphate which she handed over when her bag contained seven days of the medication which she subsequently ingested with fatal results. Even recognising medical confidentiality, those with a caring role who have not been provided with relevant information cannot meet the needs of the patient if they do not know what the risks are or know when it is appropriate to bring information to another professional charged with the care of the patient be it a nurse, doctor or support worker
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document and communicate discharge medication recommendations
Wider context from the report “(2) The note left by the psychiatrist on the medical records did not contain any recommendations as to medication. The psychiatrist was aware that Sarah’s medication was being held by her support workers as a result of the risk of mismanagement by overdosing. He was also aware that it was policy for the hospital to dispense 14 days of medication on discharge. He did not consider asking the discharging doctor to not provide Sarah with any medication on the basis that there was already a prescription in the community and although he considered that it was appropriate for the quantity of discharge medication to be reduced to seven days to reduce the risk of overdose, he did not communicate this to the medical team within the note.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of clinical abbreviations not universally understood by the medical team
Wider context from the report “(3) The note left by the psychiatrist on the medical records contained the abbreviation DSH. It was clear from the evidence given at the inquest that this was not universally understood by the medical team to refer to deliberate self harm .
Although the Trust has taken some action following the evidence being given at the inquest in that the psychiatrist after giving evidence sent an e-mail to his team detailing his reflections i.eam to request that consideration be given to a number of matters in dealing with patients at the hospital. Having considered the e-mail I did not regard this as meeting the extent of my concerns
” Open source report
Concerns raised 1 Insufficient nursing staffing capacity and resilience in the community mental health team 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
Benjamin James HART · 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
Benjamin Hart, aged 25, died by hanging at his mother’s home after contacting the Crisis team three times in the preceding two days and expressing hopelessness and suicidal feelings. The report describes limited contact with the community mental health team, a breakdown in his care-coordinator relationship, and no attempted contact before his death despite the team being notified. A principal concern was severe nursing-staff shortages, which left no capacity to allocate him a replacement care coordinator.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing capacity and resilience in the community mental health team
Wider context from the report “The Trust had a shortfall of nursing staff in the Dover and Deal area at the time that Benjamin Hart was under the community mental health team such that although 16 nurses were required to run the service, the Trust only had 8 nurses employed at the time, 2 of whom were long term sick . This left a working complement of 6 nurses to cover the whole area, which required them to take on additional duties . There was no resilience within the team and therefore when the relationship between Ben and his care coordinator broke down there was no capacity within the team to allocate him another care coordinator .
Although the Trust has regrouped, reorganised and there has been some limited recruitment the shortfall endures ; the evidence given at the inquest being that this is a national issue but it is particularly difficult to recruit within this area of Kent
” Open source report
20 May 2022 Robert Arthur Brown · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 2 Failure to define and identify carer breakdown before discharge View source Lack of a process to contact carers on discharge where no CPA is in place 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
Robert Arthur Brown · 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
Robert Arthur Brown, who had a history of suicide attempts and suicidal ideation, was discharged from hospital after four days without his wife being contacted. On 9 September 2020, he was found fatally injured at cliffs close to his home address. The principal concerns were that “carer breakdown” might not be identified before discharge and that, without a process requiring contact with a carer where no CPA was in place, anticipated care might not be available.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define and identify carer breakdown before discharge
Wider context from the report “1. The Report states that “Carer breakdown is likely to have increased the risks of suicidality on discharge as this was not addressed during the hospital admission nor on discharge”. The evidence from the KMPT witness and subsequent documentation does not address what is meant and understood to be “carer breakdown” and as such may not be identified prior to 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process to contact carers on discharge where no CPA is in place
Wider context from the report “2. As there was no process in place to require contacting a carer on discharge where there is no CPA in place a patient could be discharged without notice to a carer and as such care that is anticipated to be in place on discharge may not be available .
” Open source report
12 May 2022 Pauline Keen · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1 Lack of a policy governing communication between KMPT and the Kent County Council AMHP service to ensure timely Mental Health Act applications 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
Pauline Keen · 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
Pauline Keen fell at home in January 2021, sustained an acetabular fracture, and was later transferred to Harrier Lodge Care Home after hospital admission. Her mental health deteriorated, and although assessment under the Mental Health Act concluded that she should be admitted, there was a failure to ensure that the application was made without delay amid uncertainty over bed communication responsibilities. She died on 24 April 2021 from multiorgan failure, sepsis and bronchopneumonia.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy governing communication between KMPT and the Kent County Council AMHP service to ensure timely Mental Health Act applications
Wider context from the report “(1) There is no policy in place between KMPT and Kent County Council AMHP service as to how the organisations communicate with one another to ensure that applications under the Mental Health Act are made as soon as reasonably practicable without delay to patients .
” Open source report
3 Dec 2021 TERENCE TALBOT · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 7 Lack of formal mental capacity assessments for treatment decisions View source Lack of regular dietitian input for malnutrition View source Lack of application of emollients for severe exfoliative dermatitis View source Requirement for severely ill inpatients to attend benefit offices in person View source Inadequate provision of food and fluid to meet patient needs View source Failure of multidisciplinary meetings to focus on treatment needs View source Lack of specialist dermatology review for severe exfoliative dermatitis 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
TERENCE TALBOT · 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
Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal mental capacity assessments for treatment decisions
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular dietitian input for malnutrition
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of application of emollients for severe exfoliative dermatitis
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients . Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Requirement for severely ill inpatients to attend benefit offices in person
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim . I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate provision of food and fluid to meet patient needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of multidisciplinary meetings to focus on treatment needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist dermatology review for severe exfoliative dermatitis
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” 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 Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
Verbatim wording from the response “2) A robust monitoring of Mental Capacity Assessment of patients under our care is conducted via Mental Health Act Committee (led by the Chief Medical Officer and reporting to Trust Board) thereby ensuring the highest level of scrutiny around this. Assurance on this is provided via a Clinical Quality check (CLiQ check) process across all our services particularly the in-patient services. Since September 2021 we have implemented a streamlined process for Mental capacity assessment which was developed using Quality Improvement methodology by our Quality Improvement team. This has resulted in significant improvement in completion and documentation of Mental Capacity Assessments and Best Interest decisions where capacity is lacking.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
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 Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
Verbatim wording from the response “3) The Mental Capacity Act (MCA) training for the organisation is closely monitored, again via the Mental Health Act Committee. MCA training is mandatory for all our clinical staff and we are currently at ninety percent completion rate for this training.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
Open published response
11 Aug 2021 Hadley John Savory · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 2 Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs View source Lack of evidence of multi-agency planning meetings before discharge 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
Hadley John Savory · 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
Hadley John Savory was discharged from hospital on 25 September 2019, and his presentation later declined in the community. He was found deceased at home on 13 December 2019 after toxicological evidence indicated that he had taken a lethal dose of methadone; concerns included the absence of a multi-agency planning meeting before discharge and unclear multi-agency procedures for supporting patients with concurrent health, substance misuse and social care needs.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs
Wider context from the report “(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs ;
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of multi-agency planning meetings before discharge
Wider context from the report “(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs;
” Open source report
15 Jul 2021 FRED MALCOLM REYNOLDS (Ted) · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2 Failure to document the reason for discontinuing neurological observations View source Failure to continue neurological observations following head injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 8
Action
Include clinically indicated neurological observations in shift handovers and patient status boards, with ongoing quality assurance audits.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Train staff in electronic observations and neurological-observation competencies, with ongoing training for newly appointed nursing and medical staff.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Maintain a NICE-compliant Falls Policy specifying neurological-observation frequency and continuation until medical review.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Monitor compliance with neurological-observation standards through the Falls Care Pathway, incident reporting and quality governance reviews.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Use electronic NEWS2 observations to identify consciousness changes, trigger neurological observations when indicated, issue missed-observation alerts and support remote clinical review.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Develop and disseminate a learning bulletin reminding staff to complete Glasgow Coma Scale observations after incidents, possible strokes, head injuries and medical emergencies.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Deliver Trust-wide train-the-trainer education on neurological observations and the Glasgow Coma Scale to physical health nurses, with refresher sessions and online access.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Employ a specialist Physical Health Nurse on each ward to teach, support and supervise physical healthcare.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source See 5 more actions
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AI-generated summary
FRED MALCOLM REYNOLDS (Ted) · 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
Ted died in hospital on 30 October 2019 from an acute on chronic subdural haematoma following a head injury. He had experienced falls, increasing frailty, low sodium and anaemia, and the inquest concluded that the combination of these factors contributed to his death. Neurological observations advised after the head injury were started but not continued, and the reason was not documented in the medical records.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the reason for discontinuing neurological observations
Wider context from the report “Specialist neurology advice was given to conduct neurological observations every two hours for 48 hours following head injury. These observations were commenced but not continued. It was not possible to understand why these observations has been discontinued and there was no entry made in the medical records.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to continue neurological observations following head injury
Wider context from the report “Specialist neurology advice was given to conduct neurological observations every two hours for 48 hours following head injury. These observations were commenced but not continued. It was not possible to understand why these observations has been discontinued and there was no entry made in the medical records.
” 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 Include clinically indicated neurological observations in shift handovers and patient status boards, with ongoing quality assurance audits.
Verbatim wording from the response “2. Neurological observations are part of every handover if clinically indicated, as set out in the Inpatient Handover Protocol which was introduced in protocol in December 2018, and on the patient status board/at a glance board. Shift handover processes are regularly reviewed, and are subject to quality checks through our programme of CLIQ Quality assurance audits, in order to ensure ongoing quality improvement.” Source location 2021-0241-Response-from-KMPT_Published
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 staff in electronic observations and neurological-observation competencies, with ongoing training for newly appointed nursing and medical staff.
Verbatim wording from the response “As part of the roll out of this new system, training was provided and completed by all members of staff, and there is ongoing training offered to new nursing and medical staff. Their competencies are assessed and signed off as part of this training, further demonstrating the steps we have taken to improve staff knowledge, skills, and confidence with undertaking neuro observations.” Source location 2021-0241-Response-from-KMPT_Published
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 Maintain a NICE-compliant Falls Policy specifying neurological-observation frequency and continuation until medical review.
Verbatim wording from the response “1. Our Falls Policy, which is NICE compliant, provides guidance regarding neurological observations. It clearly sets out that neurological observations should be completed every thirty minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this becomes hourly observation for the next four hours, and then two-hourly after that, until medical review has occurred. Staff are sufficiently trained and compliant with this quality standard is monitored through our Falls Care Pathway and incident reporting. We have a well-established system for sharing lessons learnt through our quality governance meetings, and Mr Reynolds’s story has been presented there.” Source location 2021-0241-Response-from-KMPT_Published
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 Monitor compliance with neurological-observation standards through the Falls Care Pathway, incident reporting and quality governance reviews.
Verbatim wording from the response “1. Our Falls Policy, which is NICE compliant, provides guidance regarding neurological observations. It clearly sets out that neurological observations should be completed every thirty minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this becomes hourly observation for the next four hours, and then two-hourly after that, until medical review has occurred. Staff are sufficiently trained and compliant with this quality standard is monitored through our Falls Care Pathway and incident reporting. We have a well-established system for sharing lessons learnt through our quality governance meetings, and Mr Reynolds’s story has been presented there.” Source location 2021-0241-Response-from-KMPT_Published
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 Use electronic NEWS2 observations to identify consciousness changes, trigger neurological observations when indicated, issue missed-observation alerts and support remote clinical review.
Verbatim wording from the response “3. All patients on our wards have a set of vital signs recorded via NEWS2, i.e. the National Early Warning Score 2 since an electronic observation project was rolled out across 2019. This is a system designed to standardise the assessment and response to acute illness. Any patient returning from a visit to A&E, or the general hospital, have their vital signs recorded on eObs, an electronic recording system, that will calculate National Early Warning Score (NEWS2). This encompasses a consciousness level assessment, and will identify the need for Glasgow Comma Scale (GCS) to be completed. Neurological observations utilising GCS are implemented when clinically indicated, or following a reduced consciousness score from NEWS2.” Source location 2021-0241-Response-from-KMPT_Published
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 disseminate a learning bulletin reminding staff to complete Glasgow Coma Scale observations after incidents, possible strokes, head injuries and medical emergencies.
Verbatim wording from the response “8. Following Mr Reynolds’s death, the Older Adults Care Group developed and disseminated a learning bulletin to all staff, reiterating the need for neurological observations to be completed for any seen or unseen incident where a patient is presenting with a head injury, possible stroke symptoms or any medical emergency. It clearly reminded staff that observations should be completed using the Glasgow Coma Scale.” Source location 2021-0241-Response-from-KMPT_Published
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 Deliver Trust-wide train-the-trainer education on neurological observations and the Glasgow Coma Scale to physical health nurses, with refresher sessions and online access.
Verbatim wording from the response “7. Our resuscitation service has further developed a Trust-wide “Train the Trainer” course for neurological observations and the Glasgow Coma Scale, and has delivered this to all physical health nurses. Since March 2021, all the physical health nurses across the Trust have been trained, and we now offer a short refresher training session for each team, and will continue to facilitate these sessions as required. This training is also available via eLearn (virtual learning platform) for all staff to access as needed.” Source location 2021-0241-Response-from-KMPT_Published
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 Employ a specialist Physical Health Nurse on each ward to teach, support and supervise physical healthcare.
Verbatim wording from the response “6. In addition to staff training, the use of digital technology, and the improved quality governance and assurance systems in place, we have also employed specialist Physical Health Nurses on each ward as part of our nursing skill mix. This ensures that we have staff with relevant technical expertise to teach, support and supervise provision of high-quality physical health care to our patients. This was not in place at the time of Mr Reynolds’s treatment.” Source location 2021-0241-Response-from-KMPT_Published
Open published response
24 Sep 2019 Rebecca Marshall · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to obtain and share information with other trusts for patients moving to or from the area View source Failure to review patients as required View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebecca Marshall · 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
Rebecca Marshall was referred for mental health assessment after escalating self-harm, depression, anxiety and angry outbursts. After moving to university accommodation in London, there was no interagency communication between the mental health services involved in her care, and urgent referrals did not result in a senior review. She was discovered deceased in her room on 27 November 2017, and the inquest concluded that she died as a result of suicide. The principal concerns included missed opportunities in her care and inadequate arrangements for sharing information and ensuring continuity of care between trusts when she moved areas.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and share information with other trusts for patients moving to or from the area
Wider context from the report “(1) At inquest I was told that both Trusts involved: SLaM and KMPT had investigated the circumstances of Miss Marshall's death independently.
(2) At a pre-inquest review hearing on 18 October 2018 I suggested that in light of the circumstances of the case it would be preferable for a joint report to be produced focussing on the apparent lack of interagency communication which had apparently led to Miss Marshall not being reviewed as required.
(3) At inquest I was told that following the pre-inquest review hearing there had been a meeting between the two Trust's and that the report from KMPT would be exhibited to and form part of the report of SLaM Trust.
(4) Both reports identified a number of missed opportunities in Miss Marshall's care, including steps to ensure joint ownership of her care when she became a student in London.
(5) I was told at inquest of the lessons learnt by both Trusts and the actions completed.
(6) From what I was told at inquest however, it appeared that KMPT had not taken any steps to address the issues of obtaining collateral information from or sharing information with other Trusts involved in the care of one of their patients, particularly if they have moved, permanently or temporarily to / from KMPTs area .
(7) Miss Marshall formed part of what could be considered to be a particularly vulnerable group of individuals, namely a member of the student population suffering from mental health challenges whose continuity of care could not be guaranteed by good inter Trust communication.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients as required
Wider context from the report “(1) At inquest I was told that both Trusts involved: SLaM and KMPT had investigated the circumstances of Miss Marshall's death independently.
(2) At a pre-inquest review hearing on 18 October 2018 I suggested that in light of the circumstances of the case it would be preferable for a joint report to be produced focussing on the apparent lack of interagency communication which had apparently led to Miss Marshall not being reviewed as required .
(3) At inquest I was told that following the pre-inquest review hearing there had been a meeting between the two Trust's and that the report from KMPT would be exhibited to and form part of the report of SLaM Trust.
(4) Both reports identified a number of missed opportunities in Miss Marshall's care, including steps to ensure joint ownership of her care when she became a student in London.
(5) I was told at inquest of the lessons learnt by both Trusts and the actions completed.
(6) From what I was told at inquest however, it appeared that KMPT had not taken any steps to address the issues of obtaining collateral information from or sharing information with other Trusts involved in the care of one of their patients, particularly if they have moved, permanently or temporarily to / from KMPTs area.
(7) Miss Marshall formed part of what could be considered to be a particularly vulnerable group of individuals, namely a member of the student population suffering from mental health challenges whose continuity of care could not be guaranteed by good inter Trust communication.
” 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 Implement Trust-wide reminders and policy-sharing that disseminate learning from gaps in Rebecca’s care.
Verbatim wording from the response “• A programme of reminders and sharing of the Transfer and Discharge of Care policy is in place across the Trust, underpinned by sharing the learning about the gaps in Rebecca’s care and what should have happened.” Source location 2019-0313-Response-by-Kent-and-Medway-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 Incorporate South London and the Maudsley’s Transient People policy into the overarching policy document.
Verbatim wording from the response “• We have liaised with South London and the Maudsley and are incorporating their Transient People policy in to our overarching document” Source location 2019-0313-Response-by-Kent-and-Medway-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 Review the Transfer and Discharge of Care policy to cover transfers involving vulnerable populations, including students, travellers and refugees.
Verbatim wording from the response “• The Transfer and Discharge of Care policy has been reviewed to ensure that it properly addresses any and all instances of care transfer, including vulnerable populations. This includes students, travellers and refugees.” Source location 2019-0313-Response-by-Kent-and-Medway-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 Continue testing and refining care-transfer processes.
Verbatim wording from the response “You have my personal assurance as Chief Executive, that we will continue to test and refine our processes, sharing our reflection and learning from Rebecca’s story with staff who deliver front line care every day.” Source location 2019-0313-Response-by-Kent-and-Medway-NHS-Trust
Open published response
16 Nov 2018 Emmett Alexander Gillah · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Lack of staff awareness of discharge and post-discharge contact policies View source Unavailability of publicly accessible information about post-discharge contact arrangements View source Insufficient detail in discharge letters for GPs View source Inadequate communication with families about treatment decisions and discharge View source Inadequate communication of post-discharge treatment access information View source Failure to maintain scheduled telephone contact with discharged patients or their families View source See 3 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
Emmett Alexander Gillah · 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
Emmett Alexander Gillah had a history of mental illness and was discharged from mental health services at his own request. He later moved onto railway tracks and died after being struck by a train. Concerns included inadequate discharge information and follow-up arrangements, insufficient communication with his family and GP, and failures to refer him to mental health services when his mental health deteriorated.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of discharge and post-discharge contact policies
Wider context from the report “(4) There was evidence received at Inquest which indicated that KMPT staff were unaware of KMPT policies relating both to the process of discharge and subsequent arrangements to be put in place concerning the maintenance of contact with patients and where appropriate their families .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of publicly accessible information about post-discharge contact arrangements
Wider context from the report “(2) KMPT failed to act in accordance with its policy to maintain telephone contact with discharged patients or their family at least every three months for a period of three years following discharge. This policy also states that within three years from discharge from the EIS, contact may be made by a discharged patient direct with Mental Health Services in order to receive treatment. KMPT procedures were inadequate in communicating this information to either the discharged patient, their family or others who may advocate for a patient’s interests. No information is made publicly available, e.g. by way of leaflet or website, which explains the Trust’s policy in this respect .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in discharge letters for GPs
Wider context from the report “(1) The discharge letter written by KMPT on 24 April 2015 addressed to Mr Gillah, copied to his GP contained insufficient detail to assist Mr Gillah’s GP to either understand the circumstances of Mr Gillah’s discharge or the nature of the care delivered to Mr Gillah by KMPT, including the diagnosis of his mental illness .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with families about treatment decisions and discharge
Wider context from the report “(3) More broadly to those issues raised at (1) & (2), communication arrangements in existence within KMPT between staff engaged in the care of a patient and patient families who may be directly affected by decisions relating to the patient’s treatment, were inadequate e.g. Mr Gillah’s family were not consulted in relation to the decision to discharge Mr Gillah or received any formal communication in relation to the circumstances of Mr Gillah’s 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of post-discharge treatment access information
Wider context from the report “(2) KMPT failed to act in accordance with its policy to maintain telephone contact with discharged patients or their family at least every three months for a period of three years following discharge. This policy also states that within three years from discharge from the EIS, contact may be made by a discharged patient direct with Mental Health Services in order to receive treatment. KMPT procedures were inadequate in communicating this information to either the discharged patient, their family or others who may advocate for a patient’s interests . No information is made publicly available, e.g. by way of leaflet or website, which explains the Trust’s policy in this respect.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain scheduled telephone contact with discharged patients or their families
Wider context from the report “(2) KMPT failed to act in accordance with its policy to maintain telephone contact with discharged patients or their family at least every three months for a period of three years following discharge . This policy also states that within three years from discharge from the EIS, contact may be made by a discharged patient direct with Mental Health Services in order to receive treatment. KMPT procedures were inadequate in communicating this information to either the discharged patient, their family or others who may advocate for a patient’s interests. No information is made publicly available, e.g. by way of leaflet or website, which explains the Trust’s policy in this respect.
” Open source report
Concerns raised 1 Failure to maintain manageable case-loads for Care Co-ordinators 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
Mr Jamie Fairclough · 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
Mr Jamie Fairclough, who had complex difficulties and was receiving mental health services, was discharged from the Community Mental Health Team in November 2016 after unsuccessful attempts to engage with him. He was found dead at home on 9 December 2016 from chemical asphyxiation, and the inquest recorded a conclusion of suicide. Concerns included the discharge decision being contrary to the agreed care plan and made without meaningful consultation, and high caseloads for care co-ordinators.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain manageable case-loads for Care Co-ordinators
Wider context from the report “In the course of the inquest, I heard evidence that the Care Co-ordinator identified in this case had an allocated case-load of around 75 – 80 service-users . Whilst I heard evidence that the Trust has plans in place to reduce the case-loads of Care co-ordinators by August 2017, case-loads currently remain at similar levels to those which pertained when Mr Fairclough was under the care of the CMHT, notwithstanding the findings of the Trust’s own investigation into this case. Indeed, an operational manager who also gave evidence at the inquest confirmed that her current case-load was 86, in addition to managerial responsibilities .
” Open source report
13 Jan 2017 Natalie Gray · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 6 Failure to finalise discharge planning pathways for patients with personality disorder View source Ambiguous terminology in required mental health risk assessments View source Failure to record significant third-party information in Rio notes View source Failure to communicate and obtain doctor sign-off for risk ratings recorded by nurses or junior doctors View source Unclear escalation procedures for people at medium risk of self harm View source Failure to define whether risk assessments record present, chronic and historic risk View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 15
Action
Use real case examples with clinicians to improve multidisciplinary understanding of risk and its variability.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Issue Trust-wide compliance bulletins and reminders specifying terminology for missing-person risk assessments.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source
Action
Audit the quality of risk assessments as part of implementing the new Risk Summary.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source
Action
Use the countdown-to-discharge tool to support safe inpatient discharge planning, including for patients with personality disorder.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source
Action
Improve electronic-record recording and review of consultant risk assessments.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Strengthen links between Community Mental Health and Crisis Resolution Home Treatment teams for discharge decisions.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source
Action
Develop the Personality Disorder pathway, including stepdown support, specialist therapies, care-coordinator training and approved care planning.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Run a Trust-wide weekday daily crisis call involving Community Mental Health teams in discharge decisions.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source
Action
Present plans for a new integrated Personality Disorder care pathway to the Trust Board for consideration.
Stated plannedThe respondent said that this action was planned when they made their response on 19 February 2017. View source
Action
Provide specialist personality-disorder management and discharge-planning training to acute-ward staff, then roll it out Trust-wide.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Transform clinical risk assessment and management, including new training and electronic risk-assessment documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Update the Clinical Risk Policy with transition-of-care guidance and risk assessment and reassessment points.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source
Action
Implement the newly reviewed Trust risk policy and risk summary form across the organisation.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Complete the Personality Disorder review, focusing on safe transition between acute and community services.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017. View source
Action
Deliver updated mandatory training on chronic and fluctuating risk, critical risk periods and transitions in care.
Stated completedThe respondent said that this action was complete when they made their response on 19 February 2017. View source See 12 more actions
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AI-generated summary
Natalie Gray · 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
Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise discharge planning pathways for patients with personality disorder
Wider context from the report “(1) The approach to discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been finalised . It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approved/started
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguous terminology in required mental health risk assessments
Wider context from the report “(3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented, or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term 'significant' is highly subjective , is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant third-party information in Rio notes
Wider context from the report “(4) Significant information from third parties was not recorded in the Rio notes when received or at all
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and obtain doctor sign-off for risk ratings recorded by nurses or junior doctors
Wider context from the report “(2) The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk. Although risk is discussed at handovers and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear escalation procedures for people at medium risk of self harm
Wider context from the report “(3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented, or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term 'significant' is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define whether risk assessments record present, chronic and historic risk
Wider context from the report “(2) The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk . Although risk is discussed at handovers and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor
” 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 Use real case examples with clinicians to improve multidisciplinary understanding of risk and its variability.
Verbatim wording from the response “We are using learning from real case examples with our clinicians to ensure that the multidisciplinary teams understand risk, its importance and variability in a more sophisticated sense.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Issue Trust-wide compliance bulletins and reminders specifying terminology for missing-person risk assessments.
Verbatim wording from the response “• A compliance bulletin and reminders across the whole Trust, specifying terminology to be used.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Audit the quality of risk assessments as part of implementing the new Risk Summary.
Verbatim wording from the response “We have changed our approach to testing practice in relation to risk assessment. As part of the programme for implementation of the new Risk Summary, auditing is focused on quality of the risk assessment rather than just the percentage of risk assessments completed.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Use the countdown-to-discharge tool to support safe inpatient discharge planning, including for patients with personality disorder.
Verbatim wording from the response “My response in relation to this is twofold. It consists of steps already put in place to support discharge from in-patient services including those with a diagnosis of Personality Disorder in line with NICE guidance. The second part, outlining our longer term plans as part of the ongoing Personality Disorder Review being overseen by our Executive Medical Director.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Improve electronic-record recording and review of consultant risk assessments.
Verbatim wording from the response “The importance of clearly recording the Consultant’s review of risk has been discussed and action taken to ensure this happens. Changes are being made to our electronic patient record to make it easier to record and review.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Strengthen links between Community Mental Health and Crisis Resolution Home Treatment teams for discharge decisions.
Verbatim wording from the response “Dealing with the former first, the countdown to discharge tool about which I understand you received oral evidence on during the course of the inquest is key to this. In addition to this, links between Community Mental Health teams (CMHT) and the Crisis Resolution Home Treatment (CRHT) team have been strengthened. A daily Crisis Call (Monday to Friday) has been implemented Trust-wide. This allows for a patient focused discussion to occur and for the CMHT to be fully involved in any decision to discharge a patient from either a ward or the CRHT.” Source location 2017-0003-Response-by-Kent-and-Medway-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 the Personality Disorder pathway, including stepdown support, specialist therapies, care-coordinator training and approved care planning.
Verbatim wording from the response “As part of the development of the new Personality Disorder pathway we have been considering the stepdown from the acute pathway and into the community and support that is available to patients including psycho-educational groups, service user network support groups which may be provided by voluntary organisations and specialised therapy appropriate for the patients needs, additional training for Care Coordinators and approved care planning for newly admitted Personality Disorder patients.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Run a Trust-wide weekday daily crisis call involving Community Mental Health teams in discharge decisions.
Verbatim wording from the response “Dealing with the former first, the countdown to discharge tool about which I understand you received oral evidence on during the course of the inquest is key to this. In addition to this, links between Community Mental Health teams (CMHT) and the Crisis Resolution Home Treatment (CRHT) team have been strengthened. A daily Crisis Call (Monday to Friday) has been implemented Trust-wide. This allows for a patient focused discussion to occur and for the CMHT to be fully involved in any decision to discharge a patient from either a ward or the CRHT.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Present plans for a new integrated Personality Disorder care pathway to the Trust Board for consideration.
Verbatim wording from the response “The Trust’s Personality Disorder review concludes in May. The issue of safe transition between acute and community services is a central part of this review. A key aim is for all appropriate patients to be able to access specialist psychological therapies. The Trust Board will be presented with plans for a new integrated care pathway for Personality Disorder to consider at the end of May.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Provide specialist personality-disorder management and discharge-planning training to acute-ward staff, then roll it out Trust-wide.
Verbatim wording from the response “The Medical Psychotherapist and Lead Consultant for Personality Disorder unit is providing specialist advice and training to the acute wards on the management and discharge planning for their patients with Personality Disorders. In February 2017, he started training staff at Priority House on a ward by ward basis. This includes risk management formulation and mindfulness. By the end of April all staff at Priority House should have received this training. This will then be rolled out Trust-wide across the Acute Service Line.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Transform clinical risk assessment and management, including new training and electronic risk-assessment documentation.
Verbatim wording from the response “The strategy recognised that those with a diagnosed Personality Disorder are at a higher risk, and therefore require priority due to being in this high risk group. There is work underway in line with this to transform clinical risk assessment and management, both in practice and recording, with new training in place, and new risk assessment documentation about to come onto our electronic clinical record system for general” Source location 2017-0003-Response-by-Kent-and-Medway-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 Update the Clinical Risk Policy with transition-of-care guidance and risk assessment and reassessment points.
Verbatim wording from the response “We have taken a number of steps to highlight how the points of transition of care are an area of risk for those with a diagnosis of Personality Disorder. Changes have been made to our Clinical Risk Policy to reflect this. There is a flow diagram in the policy providing guidance on when to assess and reassess clinical risk and it highlights transition periods.” Source location 2017-0003-Response-by-Kent-and-Medway-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 newly reviewed Trust risk policy and risk summary form across the organisation.
Verbatim wording from the response “In January 2017 the Trust launched a newly reviewed risk policy and risk summary form, this is currently being implemented Trust-wide.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Complete the Personality Disorder review, focusing on safe transition between acute and community services.
Verbatim wording from the response “1. The approach to discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been finalised. It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approved/started.” Source location 2017-0003-Response-by-Kent-and-Medway-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 Deliver updated mandatory training on chronic and fluctuating risk, critical risk periods and transitions in care.
Verbatim wording from the response “I am aware that its development was informed by learning from Serious Incidents and near misses. Natalie’s was a case where the grading of risk was key as there was always a chronic risk which would fluctuate. Updated mandatory training focuses on the critically high risk period as well as other transitions in care. The updated training explains how the period is often referred to as the ‘Low Risk Paradox’ with risk assessed as low in one environment yet high or escalating in another.” Source location 2017-0003-Response-by-Kent-and-Medway-NHS-Trust
Open published response
27 Jan 2016 Joanna Bowring · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Failure to advise carers about behaviours indicating increased risk of suicide View source Failure to routinely include carers and actively seek their views and knowledge in risk assessment View source Failure to provide a clear understanding of the service available View source Failure to provide a care plan at initial assessment 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
Joanna Bowring · 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
Joanna Bowring had depression, paranoid delusions and suicidal thoughts and was receiving community mental health support. She died by suicide on 1 June 2015 after being struck by a high-speed train on the rail track at Boxley, Kent, with evidence of significant planning. Concerns included the lack of a clear understanding of available services and a care plan after the initial assessment, carers not being routinely included in risk assessments, and carers not being advised about behaviours indicating increased suicide risk.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise carers about behaviours indicating increased risk of suicide
Wider context from the report “(3) Carers were not advised about any behaviours that might indicate an increased risk of suicide
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely include carers and actively seek their views and knowledge in risk assessment
Wider context from the report “(2) Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not actively sought
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear understanding of the service available
Wider context from the report “(1) The patient and carer left an initial assessment conducted on 4th April 2015 without a clear understanding of the service available and without a care plan
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care plan at initial assessment
Wider context from the report “(1) The patient and carer left an initial assessment conducted on 4th April 2015 without a clear understanding of the service available and without a care plan
” Open source report
Concerns raised 2 Failure to ensure Crisis Resolution Home Treatment Team staff are conversant with the Unable to Make Contact Protocol View source Lack of clear mandatory criteria for requesting police welfare checks for patients rated 'Red' 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
Julie Margaret Rose · 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
Julie Margaret Rose, who had long-standing depression, anxiety and Obsessive Compulsive Disorder, was found dead at home on 26 April 2015 after unsuccessful attempts by mental health services to contact her and a delayed police welfare check. The concerns were that the Trust’s protocol was insufficiently clear about when a police welfare check was mandatory for high-risk patients, and that a shift co-ordinator was not familiar with the protocol despite it having been reinforced.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Crisis Resolution Home Treatment Team staff are conversant with the Unable to Make Contact Protocol
Wider context from the report “(1) Although the Trust's 'Unable to Make Contact Protocol' ("the Protocol") has been reviewed since Miss Rose's death, I am concerned that it is insufficiently clear as to when Crisis Resolution Home Treatment Team members should request a police welfare check in respect of patients who have been identified as 'Red' for the purposes of the Trust's R A G Rating System.
In particular, I am concerned the Protocol does not specifically stipulate circumstances where a request for a welfare check is mandatory (for example, after a certain period of time has elapsed since contact was last made, and / or after a certain number of attempts at contact and / or after attempts at telephone contact and a home visit have both been unsuccessful);
(2) In the course of the hearing, I heard evidence that the Protocol has been 'reinforced' across the Crisis Resolution Home Treatment Team. Notwithstanding this, a shift co-ordinator who gave evidence was clearly not conversant with the Protocol , raising questions as to the adequacy of the steps taken by the Trust to date in this respect .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear mandatory criteria for requesting police welfare checks for patients rated 'Red'
Wider context from the report “(1) Although the Trust's 'Unable to Make Contact Protocol' ("the Protocol") has been reviewed since Miss Rose's death, I am concerned that it is insufficiently clear as to when Crisis Resolution Home Treatment Team members should request a police welfare check in respect of patients who have been identified as 'Red' for the purposes of the Trust's R A G Rating System.
In particular, I am concerned the Protocol does not specifically stipulate circumstances where a request for a welfare check is mandatory (for example, after a certain period of time has elapsed since contact was last made, and / or after a certain number of attempts at contact and / or after attempts at telephone contact and a home visit have both been unsuccessful);
(2) In the course of the hearing, I heard evidence that the Protocol has been 'reinforced' across the Crisis Resolution Home Treatment Team. Notwithstanding this, a shift co-ordinator who gave evidence was clearly not conversant with the Protocol, raising questions as to the adequacy of the steps taken by the Trust to date in this respect.
” Open source report
17 Jul 2014 Joshua Lewis BROWN · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 3 Failure to inform family members about available support information and support for themselves View source Failure to engage family members in support when information sharing is declined View source Failure to verify the accuracy and interpretation of information recorded from family members 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
Joshua Lewis BROWN · 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
Joshua Lewis BROWN died on 13 June 2011 after climbing over railings at the edge of cliffs at Louisa Bay and dropping forward from the cliff. The report identified concerns about limited information-sharing and engagement between the Community Health Team and Mr Brown’s family, including the absence of a process for family members to check the accuracy of information recorded about them. It also noted that the family was not made aware of available support and information about how best to support Mr Brown and themselves.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family members about available support information and support for themselves
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members.
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage family members in support when information sharing is declined
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared . They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members.
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify the accuracy and interpretation of information recorded from family members
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members , with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members .
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” Open source report
19 May 2014 Peter Franklin · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls View source Failure of the CRISIS team to provide relevant information or advice to referring parties View source Delays in hospital and mental health trust documentation reaching GPs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Franklin · 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
Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls
Wider context from the report “(1) There was confusion in the terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made such that it was not clear between parties whether a referral, advice or assessment was sought .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the CRISIS team to provide relevant information or advice to referring parties
Wider context from the report “(2) Relevant information/advice was not provided by the CRISIS team to parties who had made referrals
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital and mental health trust documentation reaching GPs
Wider context from the report “(3) Mr. Franklin’s GP would have initiated a multidisciplinary team meeting to address the increasing frequency of attendances at hospital had he been aware of the recent hospital admission, the subsequent involvement with the mental health team and the attendances at A&E. The documentation from both hospital and mental health trusts was subject of significant delays such that none of the letters to the GP sent by either trust from July onward arrive[d] with the GP before Mr. Franklin died
” 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 Review and update the Liaison Psychiatry out-of-hours roles and responsibilities protocol to improve staff guidance.
Verbatim wording from the response “In addition we have reviewed and updated the Liaison Psychiatry roles and Responsibilities Out of Hours Protocol. This provides improved guidance to staff.” Source location 2014-0230-Response-by-Kent-Medway-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 Trial electronic discharge notifications to send GPs immediate discharge information, resolving technical issues before wider rollout.
Verbatim wording from the response “This summer KMPT began the trial of an electronic discharge notification system. By this notification of discharge is sent to GPs electronically immediately upon discharge. It” Source location 2014-0230-Response-by-Kent-Medway-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 Audit compliance with the existing written discharge-notification procedure, including GP feedback.
Verbatim wording from the response “KMPT is continuing to use the existing practice of a Written Discharge Notification being faxed to the GP within 24 hours of discharge including details of medication on the day of discharge. We are implementing an audit to ensure that this procedure is being followed which will include GPs. We recognise however that further improvement can be made and in this regard the following steps are in hand.” Source location 2014-0230-Response-by-Kent-Medway-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 Use and monitor a referral flow chart clarifying whether urgent referrals require advice or assessment.
Verbatim wording from the response “We have developed a clear process outlining the pathway for urgent referrals through a referral flow chart which includes confirmation as to whether advice or assessment is being requested. This is being monitored by the Liaison Psychiatry Service Manager and at the monthly interface meeting between the two Trusts.” Source location 2014-0230-Response-by-Kent-Medway-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 Monitor compliance with relevant policies through supervision and audit, managing performance concerns under the Trust’s performance framework.
Verbatim wording from the response “It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies. The Clinical Records Policy has been amended to reflect the importance of recording the outcome of urgent patient contact immediately on Rio, the KMPT wide electronic records system. The adherence to relevant KMPT Trust policy is monitored through supervision and audit. If there are concerns about performance this is managed through the Trust’s Performance Management Framework. Steps that can be taken include training, mentoring, working under supervision and where necessary formal capability management.” Source location 2014-0230-Response-by-Kent-Medway-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 Reinforce requirements for staff to provide complete, accurate information to carers and referring agencies.
Verbatim wording from the response “It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies. The Clinical Records Policy has been amended to reflect the importance of recording the outcome of urgent patient contact immediately on Rio, the KMPT wide electronic records system. The adherence to relevant KMPT Trust policy is monitored through supervision and audit. If there are concerns about performance this is managed through the Trust’s Performance Management Framework. Steps that can be taken include training, mentoring, working under supervision and where necessary formal capability management.” Source location 2014-0230-Response-by-Kent-Medway-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 Technical issues prevent wider rollout of electronic discharge notification until they are resolved.
Verbatim wording from the response “includes full information including diagnosis and details of medication. Unfortunately some technical issues still need to be finally resolved before wider roll out can be implemented.” Source location 2014-0230-Response-by-Kent-Medway-NHS-Trust
Open published response
13 Feb 2014 Lisa Marie Inkin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 10 Failure to record calls taken from patients by the ward View source Insufficient staffing to answer patients’ phone calls View source Failure to promptly escalate information about patients’ suicidal intent View source Lack of training or experience to recognise the importance of information about patients’ suicidal intention View source Lack of overnight supervision for patients being treated for eating disorders View source Transport difficulties disrupting access to eating disorder therapy View source Lack of local inpatient specialist eating disorder beds View source Shortage of local general adult psychiatric inpatient beds View source Lack of training or experience on when and how to escalate information about patients’ suicidal intent View source Failures in communication between local services and out-of-area psychiatric care providers View source See 7 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.
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AI-generated summary
Lisa Marie Inkin · 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
Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.
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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record calls taken from patients by the ward
Wider context from the report “7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to patients.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing to answer patients’ phone calls
Wider context from the report “7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to patients .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly escalate information about patients’ suicidal intent
Wider context from the report “6. The failure on the part of the ward staff at Cygnet to appropriately escalate the information that they received about suicidal intent on Lisa’s part until the day after the information was received and it was too late for any preventative action to be taken.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training or experience to recognise the importance of information about patients’ suicidal intention
Wider context from the report “8. Possible lack of training or experience on the part of Cygnet ward staff to understand the importance of receiving information about suicidal intention of one of their patients.
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of overnight supervision for patients being treated for eating disorders
Wider context from the report “4. The lack of overnight supervision of patients being treated for eating disorders in Kent .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Transport difficulties disrupting access to eating disorder therapy
Wider context from the report “5. The possibility of transport difficulties with potential problems on pick up such as refusal to leave the home address, not being ready at the appointed time etcetera , spending more time in transport than in therapy .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local inpatient specialist eating disorder beds
Wider context from the report “2. The complete lack of any local in-patient specialist eating disorder beds .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of local general adult psychiatric inpatient beds
Wider context from the report “1. The shortage of local General Adult Psychiatric in-patient beds .
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training or experience on when and how to escalate information about patients’ suicidal intent
Wider context from the report “9. Possible lack of training or experience on the part of ward staff at Cygnet as to when and how to escalate information about suicidal intent expressed by a 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failures in communication between local services and out-of-area psychiatric care providers
Wider context from the report “3. The communication between local services and out of area providers of psychiatric care .
” Open source report
9 Sep 2013 Ricky Anderson · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Inadequate direct assessment of discharged patients' wellbeing and needs by the Access team View source Failure to inform the GP of hospital admissions involving primary care View source Failure to put a care plan in place to establish needs before early discharge 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.
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AI-generated summary
Ricky Anderson · 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
Ricky Anderson was admitted to hospital with command hallucinations and suicidal thoughts, was discharged, and was later found suspended from a tree at Chatham Cemetery on 21 May 2012. Concerns included failures to inform his GP of his hospital admissions, reliance on family information when assessing his wellbeing after discharge, and the lack of contact with the Access team and a care plan 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate direct assessment of discharged patients' wellbeing and needs by the Access team
Wider context from the report “(2) Evidence at the Inquest that following Mr. Anderson's discharge from hospital a number of attempts were made to contact him to assess his wellbeing and needs. Although Mr. Anderson was spoken to briefly, it was accepted by the Trust that too much reliance was placed on information from family members . As a result Mr. Anderson had virtually no contact with the Access team prior to his death. I understand that a practice note has recently been drafted which is intended to be used as guidance
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of hospital admissions involving primary care
Wider context from the report “(1) It was established in evidence at the inquest that practitioners from the Kent and Medway NHS and Social Care Partnership Trust did not inform Mr. Anderson's GP of his involvement with primary care on either occasion he was admitted to hospital , resulting in him not being able to obtain a further supply of medication without the intervention of his family
” 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 Kent and Medway Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to put a care plan in place to establish needs before early discharge
Wider context from the report “Mr. Anderson's discharge from hospital occurred at an earlier stage than had been planned as he wished to leave and was deemed safe to do so. As a consequence, a care plan had not been put in place to establish his needs . I heard evidence that following Mr. Anderson's death procedures have been put in place to ensure that this situation does not reoccur
” 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