17 Apr 2026 Julie Ley · Prevention of Future Deaths report Cumbria
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Concerns raised 1 Failure of advanced life support training to cover the need for a solid surface during CPR View source
Responses linked to these concerns
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AI-generated summary
Julie Ley · 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 Ley, aged 71, died on 15 May 2025 at Westmorland General Hospital after her physical condition deteriorated while she was detained under the Mental Health Act. The inquest identified inadequate care, including failures in nutrition monitoring, physical health monitoring, transfer to a hospital able to provide appropriate treatment, and use of available legal powers to administer medication. A further concern was that CPR was performed on her bed, a soft surface, and a senior clinician was unaware that this could reduce its effectiveness.
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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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of advanced life support training to cover the need for a solid surface during CPR
Wider context from the report “(1) The consultant who was involved in performing CPR on Mrs Ley agreed that she had been in bed at the time. When asked why he had not moved her to a solid surface he replied that he had attended many advanced life support training sessions and had never been told this was necessary . In their article "The impact of compliant surfaces on in-hospital chest compressions: Effects of common mattresses and a backboard" in the journal Resucitation (Vol 80, Issue 5, May 2009) the authors note that carrying out CPR in a hospital bed may be 50% less effective. I am concerned that despite receiving training a senior clinician was unaware of this and consider that it gives rise to a risk of future deaths.
” 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 Reinforce CPR practice through resuscitation training.
Verbatim wording from the response “The Trust’s resuscitation practice is aligned with this current national guidance. In response to the matters raised in your report, the Trust has nevertheless taken steps to reinforce and assure this position through resuscitation training, policy review, equipment assurance and clinical governance processes, in order to minimise the risk of misunderstanding or inconsistent practice in the future.” Source location Response from Lancashire and South Cumbria NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current national guidance and aligned practice are considered sufficient; patients should not be moved from beds, with CPR mitigation used.
Verbatim wording from the response “Since the publication of the article cited in your report, national and international resuscitation guidance has evolved. Current Resuscitation Council UK guidance recognises that, although a firm surface is optimal, rescuers should not move a person from a soft surface, such as a bed, to the floor in order to commence CPR. The guidance emphasises that CPR should be started without delay on the bed and that, where required, chest compressions should be delivered with increased depth to compensate for mattress compliance, alongside the use of appropriate mitigation such as backboards.” Source location Response from Lancashire and South Cumbria NHS Foundation Trust
Open published response
11 Jun 2023 Marlene McCabe · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 6 Failure to communicate material patient mental health information between healthcare providers View source Failure to prevent substance misuse references and assumptions from obscuring mental health diagnoses View source Lack of clinician understanding of how to make urgent referrals into the PIMHT View source Delays in assessing patients who may appear to be or are reported to be intoxicated View source Difficulty sharing information between service providers using different databases View source Inconsistent availability of access to mental health records across service providers 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.
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AI-generated summary
Marlene McCabe · 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
Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.
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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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate material patient mental health information between healthcare providers
Wider context from the report “4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent substance misuse references and assumptions from obscuring mental health diagnoses
Wider context from the report “3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of how to make urgent referrals into the PIMHT
Wider context from the report “1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in assessing patients who may appear to be or are reported to be intoxicated
Wider context from the report “5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty sharing information between service providers using different databases
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent availability of access to mental health records across service providers
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult.
” Open source report
17 Jun 2022 Margaret Florence Joyce Stringer · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of a fail-safe, documented system preventing residents’ access to restricted items View source Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers View source Lack of staff training on the detrimental effects of isolation and loneliness in elderly people 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
Margaret Florence Joyce Stringer · 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
Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.
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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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a fail-safe, documented system preventing residents’ access to restricted items
Wider context from the report “1) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’)
Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales’ homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs Stringer . The concern arises that, in the case of a resident whose care requires access to items to be restricted, there should be a fail-safe, documented system, known to and implemented by staff, by which access to those items by the resident is prevented . In the circumstances that the possibility of a resident requiring such care may still arise, this concern exists notwithstanding the decisions now made.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
Wider context from the report “3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’))
The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide . They included the following:
i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review;
ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services;
iii. There should have been greater professional curiosity and better communication at the time of transfer;
iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA;
v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been;
vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital;
vii. The risk assessment should have been completed and provided to Nightingales;
viii. A positive behaviour support plan should have been completed and provided to Nightingales;
ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales;
x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020;
xi. The care coordinator should have been better informed at the points of transfer and discharge;
xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital;
xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded;
xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented;
xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided;
xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment;
xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document.
Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on the detrimental effects of isolation and loneliness in elderly people
Wider context from the report “2) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’)
The court heard evidence as to the potential detrimental effects of isolation and loneliness in the elderly, including evidence from the court appointed expert that isolation can be very corrosive, that it is the single most potent causative risk factor for depression in the elderly and that it can have a very detrimental effect on a person’s mental state. There is a need for this to be known amongst staff . The concern arises as one member of staff gave (disputed) evidence that they had little or no training in such matters .
” Open source report
Concerns raised 3 Lack of a written policy specifying the circumstances for group leave and responsibility for granting it View source Failure to require and define mandatory risk assessments before group leave View source Lack of defined staff-to-patient ratios and criteria for group leave View source
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
Mazielle MacKenzie · 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
Mazielle MacKenzie was a looked after child receiving care in a tier 4 hospital for young people with mental health issues. On 23 June 2018, after leaving the hospital during an organised period of leave and not returning, she was found several hours later and died despite CPR; the inquest conclusion was suicide. Concerns included the absence of a written policy for group leave, inadequate risk assessment and staffing arrangements, and shortcomings in care planning, communication and record-keeping.
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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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written policy specifying the circumstances for group leave and responsibility for granting it
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :-
(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave.
(2) That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.
(3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require and define mandatory risk assessments before group leave
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :-
(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave.
(2) That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.
(3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined staff-to-patient ratios and criteria for group leave
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :-
(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave.
(2) That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.
(3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
” 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 and disseminate a written group-leave procedure covering approval circumstances, mandatory risk assessment, MDT agreement, observation eligibility, cancellation safeguards and staffing requirements.
Verbatim wording from the response “The Trust have developed a written procedure (enclosed), which identifies the circumstances in which group leave from The Cove is granted. The Cove is the only Tier 4 CAMHS unit within the Trust. The procedure was approved at the Specialist Network Governance Group on 3 February 2022 and has been subsequently shared with staff. Until the procedure was ratified, group leave at The Cove was temporarily suspended, following receipt of your Regulation 28 notification.” Source location 2022-0005-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust_Published
Open published response
Concerns raised 5 Lack of training on policy and procedure View source Failure to establish an appropriately sufficient action plan View source Failure to complete leave documentation fully and use correct forms View source Failure to follow the AWOL procedure View source Failure to undertake handovers between Safety and Security workers 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
David Clark · 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 Clark was detained at Orchard Hospital under section 3 of the Mental Health Act and left on escorted leave on 26 June 2019. He was found in the Lancaster canal the following morning; the reported concerns included incomplete leave documentation, failure to follow the AWOL procedure, inadequate handover and training, and an outstanding action plan.
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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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training on policy and procedure
Wider context from the report “(4) That there was a lack of training on policy and procedure .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish an appropriately sufficient action plan
Wider context from the report “(5) That there remains outstanding an appropriately sufficient action 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete leave documentation fully and use correct forms
Wider context from the report “(1) That documentation in relation to leave was not completed fully and incorrect forms used
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the AWOL procedure
Wider context from the report “(2) That the AWOL procedure was not followed .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake handovers between Safety and Security workers
Wider context from the report “(3) That a handover was not undertaken between Safety and Security workers .
” 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 Implement the Section 17 leave audit and report compliance monthly through the Senior Leadership Team.
Verbatim wording from the response “o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Review Safety and Security handover arrangements, disseminate revised forms, and audit completion weekly.
Verbatim wording from the response “Unit Level:
o The SaS handover has been reviewed and new forms disseminated which include the SaS worker agreeing that the handover has taken place. The SaS paperwork is audited weekly and demonstrates that handovers are consistently being undertaken (SaS handover documentation, attachment 9).” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Review the Trust AWOL policy and procedure to reflect investigation learning.
Verbatim wording from the response “Trust Level:
o The Trust policy and procedure for AWOL has been reviewed and reflects the learning from the investigation (attachment 8).” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Roll out the RiO pre- and post-leave assessment form across the Trust.
Verbatim wording from the response “o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Audit ward use and completion of correct Safety and Security handover documentation.
Verbatim wording from the response “Trust Level:
o Learning regarding the handover has been shared with the rest of the Trust. SaS handover is part of the Trust’s Safety and Security Procedure and an audit is planned for Q1 2020/21 to ensure that the wards are using the correct documentation and this is being completed appropriately.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Complete supervision for the Ward Manager and Matron on AWOL procedures.
Verbatim wording from the response “o The Head of Nursing has completed a supervision session with the Ward Manager and Matron.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Induct all new staff to Safety and Security procedures.
Verbatim wording from the response “o All new staff are inducted to the SaS procedures (attachment 10)” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Strengthen the action plan to incorporate additional views and oversee it through the Trust Quality Committee.
Verbatim wording from the response “The Trust acknowledges that further work needed to be undertaken to the action plan to reflect the additional views of you and Mr Clark’s family. The strengthened action plan is attached. The Trust Quality Committee will oversee this action plan going forward.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 AWOL procedure training through inpatient development days and follow-up email communication.
Verbatim wording from the response “o AWOL procedure has been discussed at the Orchard In-Patient Development days and followed up with email to ensure all staff understand new process (email re AWOL procedures, attachment 7).” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Update the AWOL policy and procedure, including agreeing return times and initiating procedures when service users do not return.
Verbatim wording from the response “Unit Level:
o The Trust policy and procedure for AWOL has been updated and is in line with this staff agree with service users the time they will return from leave. If the service user has not returned by the agreed time AWOL procedures are implemented (SaS documentation, attachment 6).” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Use the pre- and post-leave assessment form in the RiO electronic care record across Secure Services.
Verbatim wording from the response “o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
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 Implementation of the Section 17 leave audit and Safety and Security role review was paused because of COVID-19.
Verbatim wording from the response “o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.” Source location 2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Open published response
12 Jul 2018 Adam James Carter · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 4 Insufficient recording and care planning of patient leave, including its rationale, benefits and risks View source Failure to retain leave authorisation documentation in accordance with section 17 leave guidance View source Failure to record nursing assessment of clinical state immediately before escorted ground leave View source Failure to document and clearly formulate patient risks in the 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
Adam James Carter · 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
Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording and care planning of patient leave, including its rationale, benefits and risks
Wider context from the report “The concern relates to record keeping.
During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following:
• Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of:
- aggression and violence;
- self harm;
- suicidal behaviour;
- absconding;
He did not feel that these risks were documented or clearly formulated in the medical notes.
• He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.
• He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion).
• He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.
Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017.
The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records.
If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave .
The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health.
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result.
I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain leave authorisation documentation in accordance with section 17 leave guidance
Wider context from the report “The concern relates to record keeping.
During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following:
• Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of:
- aggression and violence;
- self harm;
- suicidal behaviour;
- absconding;
He did not feel that these risks were documented or clearly formulated in the medical notes.
• He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.
• He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion).
• He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence .
Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017.
The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records.
If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave.
The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health.
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result.
I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record nursing assessment of clinical state immediately before escorted ground leave
Wider context from the report “The concern relates to record keeping.
During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following:
• Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of:
- aggression and violence;
- self harm;
- suicidal behaviour;
- absconding;
He did not feel that these risks were documented or clearly formulated in the medical notes.
• He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.
• He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion).
• He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.
Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017.
The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records.
If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave.
The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health.
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result.
I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document and clearly formulate patient risks in the medical records
Wider context from the report “The concern relates to record keeping.
During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following:
• Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of:
- aggression and violence;
- self harm;
- suicidal behaviour;
- absconding;
He did not feel that these risks were documented or clearly formulated in the medical notes.
• He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.
• He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion).
• He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.
Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017.
The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records.
If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist , and why he or she has been granted leave.
The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health.
It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result.
I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” 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 Pilot leave diaries in secure services to assess whether they improve the quality of post-leave documentation.
Verbatim wording from the response “How leave went for the patient should already be documented and discussed in the wider MDT forum; in addition a pilot of “leave diaries” is currently taking place in our secure services, if it is found to increase the quality of post leave documentation this will later be rolled out to all wards.” Source location 2018-0226-Response-by-Lancashire-Care-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 Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.
Verbatim wording from the response “Once leave has been agreed by the Multi Disciplinary Team, the nursing team on each ward will be prompted to fully consider the patients risks and state of mind immediately prior to the patient taking this leave, and reminded to document their up to date decision in the clinical record.” Source location 2018-0226-Response-by-Lancashire-Care-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 Consider amending the Leave Policy to include additional requirements for care planning regular patient leave.
Verbatim wording from the response “Leave that is given regularly to a patient is already discussed and agreed in the context of the Multi Disciplinary Team, and should be documented in the clinical record, however some points around how this is care planned are not currently included in our Leave Policy and so the Mental Health Law Manager will consider a minor amendment to the policy by 28 September 2018.” Source location 2018-0226-Response-by-Lancashire-Care-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 Write to consultants and ward managers reiterating the need to document the rationale, risks and benefits for each patient accessing leave.
Verbatim wording from the response “The Clinical Director will write to consultants and ward managers about these actions by 14 September 2018 and reiterate the importance of documenting the rationale, risks and benefits for each individual accessing leave.” Source location 2018-0226-Response-by-Lancashire-Care-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 Include the actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.
Verbatim wording from the response “The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers will then review the findings from these audits and feed the results back during clinical supervision with their teams.” Source location 2018-0226-Response-by-Lancashire-Care-NHS-Trust
Open published response
Concerns raised 5 Failure to relay service-user messages to the MDT View source Failure to review relevant clinical records during MDT meetings View source Inadequate record keeping during MDT meetings View source Failure to consider patients referred or handed over to the MDT View source Failure to communicate MDT follow-up decisions to patients View source See 2 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
Robert Cardwell · 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 Cardwell was under the care of a Home Treatment Team but was discharged after information about his missed appointment and request for a further appointment was not passed to the multidisciplinary team. He later expressed suicidal thoughts, described a plan to hang himself using a football scarf, and was found deceased at home on 29 September 2016 after hanging himself. Concerns included failures in communication, failure to discuss or follow up his request for an appointment, and inadequate record keeping during multidisciplinary team meetings.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to relay service-user messages to the MDT
Wider context from the report “On the 6th July 2016 a nurse at the Trust contacted Mr Cardwell to find out why he had not attended his appointment with the Psychiatrist that day. Mr Cardwell told the nurse that he had been unable to attend the appointment because he had no petrol. He also advised that he had no phone credit and had therefore been unable to contact them. Mr Cardwell reported that his ex-partner had stolen his bankcard and that all the money had gone from his account. The nurse advised that this information would be passed to the MDT for their consideration the following day. Mr Cardwell wanted another appointment but he said it would have to be a home visit.
Whilst Mr Cardwell was discussed at the MDT meeting on the 7th July and discharged, I found on the evidence that the message explaining his non-attendance and requesting a further appointment was not relayed to the MDT . Had that message been relayed to the MDT, I found that Mr Cardwell would have been offered a further appointment and would not have been discharged at that time. This failure in communication is a matter of concern. I am concerned about the process by which messages are relayed from service users to the MDT team . The nurse explained that the information was passed on to be taken up by the Duty Worker and it should then have been reported to the team. The nurse also recorded the contact in Mr Cardwell’s clinical record but these were not looked at during the course of the MDT meeting.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant clinical records during MDT meetings
Wider context from the report “On the 6th July 2016 a nurse at the Trust contacted Mr Cardwell to find out why he had not attended his appointment with the Psychiatrist that day. Mr Cardwell told the nurse that he had been unable to attend the appointment because he had no petrol. He also advised that he had no phone credit and had therefore been unable to contact them. Mr Cardwell reported that his ex-partner had stolen his bankcard and that all the money had gone from his account. The nurse advised that this information would be passed to the MDT for their consideration the following day. Mr Cardwell wanted another appointment but he said it would have to be a home visit.
Whilst Mr Cardwell was discussed at the MDT meeting on the 7th July and discharged, I found on the evidence that the message explaining his non-attendance and requesting a further appointment was not relayed to the MDT. Had that message been relayed to the MDT, I found that Mr Cardwell would have been offered a further appointment and would not have been discharged at that time. This failure in communication is a matter of concern. I am concerned about the process by which messages are relayed from service users to the MDT team. The nurse explained that the information was passed on to be taken up by the Duty Worker and it should then have been reported to the team. The nurse also recorded the contact in Mr Cardwell’s clinical record but these were not looked at during the course of the MDT meeting .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate record keeping during MDT meetings
Wider context from the report “On the 6th August 2016 Mr Cardwell was seen in hospital by a member of the liaison team following a significant overdose. He was later discharged from hospital and he queried with the HTT on the 9th August 2016 (on attending West Strand House in person) whether he was due a follow-up with the HTT. Mr Cardwell was told that the MDT would be asked the following day and that someone would contact him from the team to let him know. I found that the message was - on this occasion - relayed by the Duty Practitioner to the MDT on the 10th August 2016. However, the MDT did not discuss Mr Cardwell and nothing was recorded about him . No-one contacted Mr Cardwell back to advise him as to whether or not he would have an appointment with the HTT. I heard evidence that the MDT meeting could be disorganised. I am concerned that Mr Cardwell was not considered by the team, despite the message being handed over to them. I am also concerned about a lack of record keeping during the MDT . Even where patients are discussed, the notes appear to be very brief .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider patients referred or handed over to the MDT
Wider context from the report “On the 6th August 2016 Mr Cardwell was seen in hospital by a member of the liaison team following a significant overdose. He was later discharged from hospital and he queried with the HTT on the 9th August 2016 (on attending West Strand House in person) whether he was due a follow-up with the HTT. Mr Cardwell was told that the MDT would be asked the following day and that someone would contact him from the team to let him know. I found that the message was - on this occasion - relayed by the Duty Practitioner to the MDT on the 10th August 2016. However, the MDT did not discuss Mr Cardwell and nothing was recorded about him. No-one contacted Mr Cardwell back to advise him as to whether or not he would have an appointment with the HTT. I heard evidence that the MDT meeting could be disorganised. I am concerned that Mr Cardwell was not considered by the team, despite the message being handed over to them. I am also concerned about a lack of record keeping during the MDT. Even where patients are discussed, the notes appear to be very brief.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate MDT follow-up decisions to patients
Wider context from the report “On the 6th August 2016 Mr Cardwell was seen in hospital by a member of the liaison team following a significant overdose. He was later discharged from hospital and he queried with the HTT on the 9th August 2016 (on attending West Strand House in person) whether he was due a follow-up with the HTT. Mr Cardwell was told that the MDT would be asked the following day and that someone would contact him from the team to let him know. I found that the message was - on this occasion - relayed by the Duty Practitioner to the MDT on the 10th August 2016. However, the MDT did not discuss Mr Cardwell and nothing was recorded about him. No-one contacted Mr Cardwell back to advise him as to whether or not he would have an appointment with the HTT . I heard evidence that the MDT meeting could be disorganised. I am concerned that Mr Cardwell was not considered by the team, despite the message being handed over to them. I am also concerned about a lack of record keeping during the MDT. Even where patients are discussed, the notes appear to be very brief.
” Open source report
Concerns raised 9 Failure to complete mental health and suicide risk assessments View source Failure of mental health and substance misuse services to share patient information View source Failure to review available records fully during assessment View source Failure to assess coexisting mental health issues in people presenting with substance misuse View source Lack of a shared electronic mental health record system across teams View source Incomplete team incident reviews of deaths View source Failure to record negative assessment findings View source Cancellation of planned face-to-face mental health assessments View source Delays in learning and implementing lessons from identified concerns View source See 6 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
Stephen McDermott · 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 McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete mental health and suicide risk assessments
Wider context from the report “3) There was evidence of poor training with regards to incomplete assessments and poor record keeping. In respect of the telephone call from the GP to ████████ at the SPOA on 16 March 2015, there is no evidence in the records to evidence that ████████ asked any questions regarding Mr McDermott’s mental health , despite the fact that the GP was requesting referral into services for a mental health assessment. There is no evidence that ████████ followed the ‘Storm’ guidance (guidance that had not been disclosed at the inquest) to assess suicide risk factors or mental health issues. His evidence was that he would have asked the relevant questions but just did not document the responses, but I found on the balance of probabilities that the questions had not been asked;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health and substance misuse services to share patient information
Wider context from the report “7) It was apparent that when patients are assessed and treated by other services, in this case Discover Drug and Alcohol Recovery Services provided by Greater Manchester West NHS Foundation Trust [‘GMW’], LCFT do not have access to GMW records and vice versa . In a case such as this, where there is a significant overlap between mental health issues and substance misuse issues, it is of significant concern that services do not / cannot share information to assist in their assessment processes to ensure that they are in possession of the full picture of an individual’s presentation;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review available records fully during assessment
Wider context from the report “2) In addition to the problems highlighted above of not having all records on one system, there was evidence of poor use of the records that were available resulting in liaison nurses who were assessing Mr McDermott having an incomplete picture :
a) During the GP’s telephone call to ████████ at the Single Point of Access team on 16 March 2015, ████████ did not check the full records to learn the background of Mr McDermott’s recent admission following an overdose;
b) During her assessment of Mr McDermott on 27 March 2015, ████████ mental health liaison nurse, was only aware that Mr McDermott had taken an overdose of drugs and alcohol. She was unaware that Mr McDermott had been brought to Accident and Emergency whilst intoxicated having been located near the train station by police and having reported to them that he was having thoughts of jumping in front of a train, a fact that was readily available in the records;
c) Following his assessment of Mr McDermott on 6 April 2015, ████████ mental health liaison nurse, discharged Mr McDermott without a plan for referral into the crisis team for assessment. Part of his rationale for this was that Mr McDermott told him he had an appointment with Mindsmatter on 9 April. This was incorrect (this date was in fact due to be the first face-to-face appointment with the SPOA, which was subsequently cancelled) and demonstrates that ████████ either did not have access to or did not properly check relevant 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess coexisting mental health issues in people presenting with substance misuse
Wider context from the report “5) Mr McDermott’s problems were repeatedly treated as substance misuse issues without any consideration or assessment of whether mental health issues might be the underlying cause of the substance misuse issues. Individuals assessing Mr McDermott repeatedly had their views clouded by substance misuse issues , which prevented Mr McDermott from being referred into mental health services for assessment. Although the Trust’s ‘Team Incident Review’ [‘TIR’] identified that a “more flexible approach” was required in relation to overlapping substance misuse and mental health issues, there was no evidence at the inquest that trust policies or procedures have changed in this respect, nor any evidence of staff being trained to approach such cases differently ;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a shared electronic mental health record system across teams
Wider context from the report “1) The electronic record system is not the same across all mental health teams (Single Point of Access, Crisis Team, Mindsmatter) meaning that not all relevant records were available at each point of assessment of Mr McDermott – Mindsmatter use ‘IAPTS’ and the other teams use ‘ECR Blue’ as opposed to there being one record system for all to use and to ensure mental health records are in one place . Although ████████ gave evidence that Mindsmatter now has access to ECR Blue and the other teams have access to IAPTS, his evidence was that the system remains “clunky.” His evidence was that a new electronic system has been commissioned, but he did not know whether it was one system for all teams to have access to and/or whether the problems highlighted in this case would remain. In addition, the system is not due to be implemented for a further 18 months. He agreed that having one electronic system used by all teams would be of benefit;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete team incident reviews of deaths
Wider context from the report “8) Although LCFT instigated a ‘Team Incident Review,’ the inquest found that it was incomplete in some important respects , most notably in that it made no reference whatsoever to the telephone call from the GP to ████████ on 16 March 2015, an incident which I found was the real trigger point at which Mr McDermott ought to have been referred into services. Further, the TIR fails to address adequately or at all, a number of the concerns raised in this Regulation 28 report . Since the purpose of a TIR is to investigate a death to identify areas of concern with a view to learning lessons, it is a substantial concern that the TIR was incomplete in several respects;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record negative assessment findings
Wider context from the report “4) Following on from the above, of particular concern was that ████████ line manager, ████████ (the Access and Treatment Team Deputy Manager) said in evidence that negative answers to questions would not necessarily always be documented . ████████, the independent expert, ████████ and ████████ all agreed that the records should always be a complete picture with recording of negative answers being an essential part of that ;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Cancellation of planned face-to-face mental health assessments
Wider context from the report “6) Following a telephone call made to the SPOA by Mr McDermott’s mother on 1 April 2015, in which she advised that she feared he was at risk of suicide and had written a suicide note, contact was made with Mr McDermott who confirmed he could keep himself safe so an appointment was made for him to have a face-to-face assessment at the SPOA on 9 April 2015. However, this appointment was cancelled by the SPOA team on 7 April because Mr McDermott had been assessed by ████████ on 6 April following his attendance at Accident and Emergency. The expert’s view, with which ████████ agreed, was that this was a missed opportunity to have a face-to-face assessment of Mr McDermott in a non-crisis situation;
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in learning and implementing lessons from identified concerns
Wider context from the report “9) Although ████████ accepted that a number of issues had been highlighted by the inquest that he would be “feeding back” and “learning lessons from,” it is a significant concern that almost two years have elapsed since Mr McDermott’s death and lessons have not yet been learned , especially since the Trust had been in possession of the expert’s report for over 3 months prior to the inquest .
” Open source report
Concerns raised 11 Failure of RMNs to record post-consultation and post-review information in ACC T documentation View source Failure to undertake assessments in the way recommended for prisoner safety View source Failure to undertake referred psychiatric assessment View source Failure of RMNs to make medical-record enquiries about self-harm or suicide responses View source Failure of RMNs to read ACC T documentation for collateral information relevant to delusional-disorder diagnosis View source Reliance by RMNs on summaries of ACC T documentation instead of independent review View source Formation of mental health conclusions without reviewing relevant documentation or undertaking mental health assessment View source Failure to record referrals concerning psychiatric state in the medical record View source Failure of RMNs to assess patients with obvious delusional symptoms View source Failure to provide sufficient information demonstrating improvement or resolution of safety matters View source Lack of supervision or retraining for RMNs remaining in clinical posts View source See 8 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
Andrew Gus PEEBLES · 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
The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of RMNs to record post-consultation and post-review information in ACC T documentation
Wider context from the report “(2) No entries were made by the RMN after consultations/ACC T reviews with the deceased in the ACC T documentation resulting in no information being available to discipline officers managing Mr Peebles
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake assessments in the way recommended for prisoner safety
Wider context from the report “(9) the attendance at inquest by the healthcare manager without sufficient information to demonstrate that matters had improved, been resolved etcetera and having heard the suggestions to minimise future deaths by the expert ████████ consultant forensic psychiatrist who advises at a national level on matters of prisoner safety, effectively responded that that wasn't the way the Trust undertook its assessments
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake referred psychiatric assessment
Wider context from the report “(7) on referral on 25 May 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of RMNs to make medical-record enquiries about self-harm or suicide responses
Wider context from the report “(1) No enquiries were made by the RMN in the medical records specifically commenting upon the replies to questions in respect of self-harm or suicide , the only significant entries in the medical records on this subject being made by RGNs
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of RMNs to read ACC T documentation for collateral information relevant to delusional-disorder diagnosis
Wider context from the report “(4) No reading by the RMN of the ACC T documentation for collateral information necessary to assist in the diagnosis of a delusional disorder
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance by RMNs on summaries of ACC T documentation instead of independent review
Wider context from the report “(5) RMN relying upon the summary of the ACC T documentation provided to her by the Senior Officer undertaking the ACC T review rather than assessing the documentation for herself to form a view of the information from a mental health perspective
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Formation of mental health conclusions without reviewing relevant documentation or undertaking mental health assessment
Wider context from the report “(6) RMN formed the view that Mr Peebles was not suffering from any mental health condition without having reviewed the ACC T documentation, discipline documentation or undertaking any mental health assessment prior to informing the deceased of her decision .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record referrals concerning psychiatric state in the medical record
Wider context from the report “(7) on referral on 25 May 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of RMNs to assess patients with obvious delusional symptoms
Wider context from the report “(3) No assessment by an RMN of a patient suffering obviously delusional symptoms on several occasions
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient information demonstrating improvement or resolution of safety matters
Wider context from the report “(9) the attendance at inquest by the healthcare manager without sufficient information to demonstrate that matters had improved, been resolved etcetera and having heard the suggestions to minimise future deaths by the expert ████████ consultant forensic psychiatrist who advises at a national level on matters of prisoner safety, effectively responded that that wasn't the way the Trust undertook its assessments
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of supervision or retraining for RMNs remaining in clinical posts
Wider context from the report “(8) RMN remains in the clinical post within the trust and does not appear to have undergone any supervision or retraining
” Open source report
Concerns raised 5 Failure to hold a final discharge meeting for discharge to a rehabilitation unit View source Failure to manage an identified risk during patient transport View source Failure to arrange a care programme approach meeting before discharge View source Failure to arrange familiarisation visits before discharge to a rehabilitation unit View source Failure to assess current presentation and circumstances before rescinding detention and arranging discharge View source See 2 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
Tracey Lynch · 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
Tracey Lynch, who had emotionally unstable personality disorder, died by suicide after hanging herself in her room at Oswald House on 9 October 2015. The report identified concerns about the lack of a final discharge meeting, familiarisation visits and appropriate escorted transport, and about the absence of adequate assessments and care planning after her presentation changed and she was transferred between services.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a final discharge meeting for discharge to a rehabilitation unit
Wider context from the report “1. Despite the fact that there had been a clear change in the presentation of Tracey Lynch following the CPA Meeting on the 22nd June and despite the fact that arrangements for discharge were not in place until the 28th September 2015 no final discharge meeting was held , that is despite the fact that the responsible clinician, ████████ the care co-ordinator ████████ and the deputy manager from Oswald House ████████ had all indicated that they wished there to be a final discharge meeting. There seemed to be no system in place to ensure that such a meeting would take place and in order to ensure that appropriate management would take place of the discharge to a rehabilitation unit.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage an identified risk during patient transport
Wider context from the report “3. The evidence was that ████████ the mother of Tracey Lynch, had alerted the care co-ordinator and the responsible clinician with her concerns that her daughter’s state of mind was such that unless she was properly and appropriately escorted in the transport from The Harbour to Oswald House that she would attempt to jump from the motor vehicle. Those concerns were not addressed such that on the 28th September when only escorted by the occupational therapist who was driving the vehicle Miss Lynch was able to grab the steering wheel and cause a serious accident on the M55 motorway. Despite the fact that this risk had previously been identified there was no attempt to seek to manage that in an appropriate way .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange a care programme approach meeting before discharge
Wider context from the report “4. Having been detained by the Police and having then been assessed by Mental Health Practitioners Tracey Lynch was then detained under Section 3 of the Mental Health Act 1983. She was taken from Preston Police Station to The Harbour at Blackpool. She was placed on a different ward and with a different responsible clinician, ████████ Without carrying out any form of assessment whatsoever and with only a cursory glance at previous records ████████ immediately rescinded the Section 3 and without any consideration of the change in circumstance and presentation of Miss Lynch arranged for her immediate discharge to Oswald House. The evidence was that the Consultant Psychologist ████████ who had previously been dealing with Miss Lynch attempted to contact ████████ but her offer of assistance was refused. Having been detained for a second time there was no assessment and no care programme approach meeting arranged . That appeared to be a serious systems failure.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange familiarisation visits before discharge to a rehabilitation unit
Wider context from the report “2. The evidence was that familiarisation visits would have been of considerable assistance to Miss Lynch in the lead up to her discharge to Oswald House. Despite that being accepted there appeared to be no system in place to ensure that such familiarisation visits would take place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess current presentation and circumstances before rescinding detention and arranging discharge
Wider context from the report “4. Having been detained by the Police and having then been assessed by Mental Health Practitioners Tracey Lynch was then detained under Section 3 of the Mental Health Act 1983. She was taken from Preston Police Station to The Harbour at Blackpool. She was placed on a different ward and with a different responsible clinician, ████████ Without carrying out any form of assessment whatsoever and with only a cursory glance at previous records ████████ immediately rescinded the Section 3 and without any consideration of the change in circumstance and presentation of Miss Lynch arranged for her immediate discharge to Oswald House . The evidence was that the Consultant Psychologist ████████ who had previously been dealing with Miss Lynch attempted to contact ████████ but her offer of assistance was refused. Having been detained for a second time there was no assessment and no care programme approach meeting arranged. That appeared to be a serious systems failure.
” Open source report
24 Nov 2015 Piotr Grzegorz Kucharz · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to clearly require physical entry into patients’ rooms to check the environment during observations View source Failure to clearly require verbal engagement during patient observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Piotr Grzegorz Kucharz · 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
Piotr Kucharz was admitted to a mental health hospital and later found unresponsive after using a cord as a ligature; he died in hospital on 12 October 2014. Concerns included the absence of an effective translation service and a lack of consistency and clarity among staff about what constituted an effective observation, including whether staff should enter a patient’s room and engage verbally.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly require physical entry into patients’ rooms to check the environment during observations
Wider context from the report “1. Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April 2014. At the time he sought to strangle himself with a cord he was an informal patient at the Conway Ward at Parkwood, a mental health facility in Blackpool. At his inquest, evidence was heard from a number of members of staff as regards what constitutes an effective observation. He was the subject of what were described as Safety and Security [SAS] and general observations, the completion of which was the responsibility of a number of members of care staff. The evidence heard from staff raised an area of concern because that evidence indicated quite clearly that there was a lack of consistency and clarity as regards what constitutes an effective observation . An independent expert witness indicated in a report that he completed prior to the inquest that he felt custom and practice was such that some staff were merely checking on the “whereabouts” of the patient.
Some staff felt that they were expected to enter the room of the patient and to try to engage with him and to check the room environment for anything that may pose a risk to him. Others felt that whether they were expected to actually enter a patient’s room to conduct the observation could vary depending on the level of risk a particular patient presented , in other words that they felt they had an element of discretion as regards whether they entered the room. This evidence appeared to be in contrast to a Trust policy.
In the case of Piotr Kucharz, as can be seen above he had limited understanding of English, and a number of staff gave evidence that he remained in his room throughout his time on the Conway Ward and did not wish to engage with them. Nevertheless, the author of the Trust’s Sudden Untoward Incident Review document agreed that there was no such discretion and that staff ought to enter the room to complete and effective observation.
At the conclusion to the inquest I expressed the view that I was concerned that there is a risk of future deaths because staff remain unclear about what amounts to an effective observation, and more specifically whether there are circumstances which may allow them to refrain from verbally engaging with a patient, or from physically entering a patient’s room to check the environment , and that should that lack of consistency and clarity prevail, other patients may be placed at risk as a result of inadequate observations.
For the avoidance of doubt, I confirm that I am of the opinion that the above concern remains valid despite the fact that further to Piotr Kucharz’s death the provision of mental health care for patient’s such as Piotr has moved from the Conway Ward at Parkwood to another facility within my jurisdiction at which members of staff who were working at the time of Piotr’s death continue to be employed in a similar capacity.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly require verbal engagement during patient observations
Wider context from the report “1. Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April 2014. At the time he sought to strangle himself with a cord he was an informal patient at the Conway Ward at Parkwood, a mental health facility in Blackpool. At his inquest, evidence was heard from a number of members of staff as regards what constitutes an effective observation. He was the subject of what were described as Safety and Security [SAS] and general observations, the completion of which was the responsibility of a number of members of care staff. The evidence heard from staff raised an area of concern because that evidence indicated quite clearly that there was a lack of consistency and clarity as regards what constitutes an effective observation . An independent expert witness indicated in a report that he completed prior to the inquest that he felt custom and practice was such that some staff were merely checking on the “whereabouts” of the patient.
Some staff felt that they were expected to enter the room of the patient and to try to engage with him and to check the room environment for anything that may pose a risk to him. Others felt that whether they were expected to actually enter a patient’s room to conduct the observation could vary depending on the level of risk a particular patient presented, in other words that they felt they had an element of discretion as regards whether they entered the room. This evidence appeared to be in contrast to a Trust policy.
In the case of Piotr Kucharz, as can be seen above he had limited understanding of English, and a number of staff gave evidence that he remained in his room throughout his time on the Conway Ward and did not wish to engage with them. Nevertheless, the author of the Trust’s Sudden Untoward Incident Review document agreed that there was no such discretion and that staff ought to enter the room to complete and effective observation.
At the conclusion to the inquest I expressed the view that I was concerned that there is a risk of future deaths because staff remain unclear about what amounts to an effective observation, and more specifically whether there are circumstances which may allow them to refrain from verbally engaging with a patient , or from physically entering a patient’s room to check the environment, and that should that lack of consistency and clarity prevail, other patients may be placed at risk as a result of inadequate observations.
For the avoidance of doubt, I confirm that I am of the opinion that the above concern remains valid despite the fact that further to Piotr Kucharz’s death the provision of mental health care for patient’s such as Piotr has moved from the Conway Ward at Parkwood to another facility within my jurisdiction at which members of staff who were working at the time of Piotr’s death continue to be employed in a similar capacity.
” 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 Issue an internal patient safety alert reminding inpatient services of the current observation policy and procedure.
Verbatim wording from the response “In the interim, until this new policy and procedure is developed and implemented, an internal patient safety alert has been issued to remind staff of the current policy and procedure. This alert was sent to all inpatient services across the Trust.” Source location 2015-0465-Response
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 implement a revised observation policy and procedure by 31 March 2016.
Verbatim wording from the response “The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016.” Source location 2015-0465-Response
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 observation policy and procedure using learning from serious incidents and national best practice.
Verbatim wording from the response “The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016.” Source location 2015-0465-Response
Open published response
Concerns raised 3 Lack of emergency department visibility of referral acceptance and assessment timing View source Failure of the referral process to identify and rectify errors View source Failure of the Mental Health Liaison Team to identify patients believed to be referred and awaiting assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Williams · 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
On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency department visibility of referral acceptance and assessment timing
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place . Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the referral process to identify and rectify errors
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified . In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Mental Health Liaison Team to identify patients believed to be referred and awaiting assessment
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment .
” 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 Explore developing an email referral system providing receipt confirmation and an approximate assessment time.
Verbatim wording from the response “A further option we are exploring is the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team with the patient's details and a brief reason for referral. The Mental Health Liaison Team would then acknowledge receipt of the email and also give approximate time of assessment. The referral information is already recorded within the Mental Health Liaison referral log book, however this approach we are looking to implement will ensure that positive confirmation is provided to Emergency Department staff.” Source location 2015-0421-Response-by-Lancashire-Care-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 Plan to utilise the CRISP board to record referrals to specialist teams.
Verbatim wording from the response “Within the Emergency Department they use the CRISP board to record the referrals made to specialist teams and we are looking to utilise this technology.” Source location 2015-0421-Response-by-Lancashire-Care-NHS-Trust
Open published response
13 Feb 2015 Robert Paul Yarnell · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Unclear procedures and protocols for continuing care when service users move outside the Trust area View source Delays or non-provision of continuing mental health care when service users move outside the Trust area 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 Paul Yarnell · 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 Paul Yarnell died after jumping from Barton Bridge on the M60 Motorway on 8 October 2014, causing multiple injuries. He had been receiving mental health care following a hospital admission, but moving out of the area led to a significant delay in continuing care. Concerns were raised that unclear procedures for transferring care between areas could leave service users without needed support and create risky situations.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear procedures and protocols for continuing care when service users move outside the Trust area
Wider context from the report “ii. The procedures and protocols currently in place within Lancashire Care NHS Foundation Trust for the continuing care of a service user, when that service user moves out of the area, are not clear and give rise to risky and potentially fatal situations .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays or non-provision of continuing mental health care when service users move outside the Trust area
Wider context from the report “i. Due to Mr Yarnell moving out of the area there was a significant delay in the continuing care that he received following his discharge from hospital after a section 2 admission under the Mental Health Act 1983. Although Mr Yarnell did contact the services of his own volition some time later, I have concerns that in future cases a service user who requires ongoing support and treatment from Lancashire Care NHS Foundation Trust, may not receive it due to residing outside the Trust area .
” Open source report
29 Aug 2014 Stephen James Morris · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Failure to exchange sufficient relevant mental health information during cross-area transitions View source Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team View source Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication 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
Stephen James Morris · 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 James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to exchange sufficient relevant mental health information during cross-area transitions
Wider context from the report “Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:
• I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool.
• By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health.
• When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly .
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team
Wider context from the report “Having concluded this inquest, I now write to you to confirm that in my view you should take action because:
• I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made.
• That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision.
• That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care.
I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns.
” 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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication
Wider context from the report “Having concluded this inquest, I now write to you to confirm that in my view you should take action because:
• I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made.
• That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision.
• That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care.
I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns.
” Open source report
20 Dec 2013 Roy Frank Fletcher · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Failure of Post Incident Reviews to thoroughly and comprehensively explore all relevant issues 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
Roy Frank Fletcher · 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
Roy Frank Fletcher, who had a long history of depression, left Parkwood Hospital on 6 July 2010 after exiting through a partially open ward door and following another service user out of the building. He was found deceased at approximately 7.30 pm at a local holiday park, having taken his own life by hanging. The report raised concerns that the Trust’s post-incident review was not sufficiently thorough, including that it had not explored how he exited or whether similar incidents had occurred.
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 Lancashire & South Cumbria NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Incident Reviews to thoroughly and comprehensively explore all relevant issues
Wider context from the report “I am concerned that the review undertaken was significantly lacking for the following reasons:
• CCTV footage shows that at the relevant time the Deceased shows him following another Service User out of the reception area at the hospital. It seems no steps had been taken to speak to that Service User in order to establish if he had been aware that he was a vehicle for the Deceased’s exit from hospital, and if so on what basis.
• Further, the oral evidence provided to the inquiry by ████████ suggested that the review had not explored whether other service users had left the relevant ward, or the reception area of the hospital in similar circumstances .
Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:
• When Post Incident Reviews are undertaken it is important that they are thorough and comprehensive and that all of the relevant issues are explored prior to recommendations being made arising from that review and the organisation making recommendation for remedial action, if any, to be undertaken.
• If such reviews are lacking, there is a risk that an organisation may not appreciate whether a problem is a persistent one, potentially helpful changes to procedures may not be put in place and future deaths may occur which may otherwise have been prevented.
” 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