16 Sep 2025 Christian Barry · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Lack of a formal system for communication, information sharing and handover between the respite facility and the Intensive Support Service 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
Christian Barry · 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
Christian Barry, who had recent alcohol withdrawal and worsening mental health symptoms, was found hanging in a bathroom at a respite facility on 6 January 2025 and was pronounced dead at the scene. The principal concern was the lack of a formal system for communication, information sharing and handover between the respite facility and the clinical service responsible for his care, including after a planned 48-hour review was missed.
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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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal system for communication, information sharing and handover between the respite facility and the Intensive Support Service
Wider context from the report “There remains no system for formal communication, sharing and handover of information about patients who are admitted to the respite facility operated by Leeds Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support Service at Leeds and Yorkshire Partnership Foundation Trust. It was candidly accepted in evidence that there needs to be an improvement in communication channels and information sharing for the partnership to run efficiently and effectively and to mitigate risk.
” Open source report
1 Nov 2021 Neil Peter Bastock · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 14 Unavailability of psychological input to care planning View source Lack of continuity in treatment View source Bed-availability pressure influencing section rescission decisions View source Absence of ward management leadership for care provision View source Incomplete nursing records View source Failure to notify police when a patient at suicide risk goes missing View source Failure to evaluate a patient’s situation and required action after return to the ward View source Failure to heed family warnings about a patient’s fitness for discharge View source Failure to establish alternative accommodation and transition arrangements before discharge consideration View source Failure to undertake a formalised mental capacity assessment before section rescission decisions View source Failure to sufficiently consider the significance of potential farewell behaviour View source Use of a responsible clinician with insufficient role experience for section rescission decisions View source Failure to involve family in section rescission decisions View source Failure to update the care plan before section rescission View source See 11 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
Neil Peter Bastock · 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
Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.
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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of psychological input to care planning
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning . The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in treatment
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity . The responsible clinician was a locum who had recently taken over from another locum psychiatrist . There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Bed-availability pressure influencing section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of ward management leadership for care provision
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided . There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete nursing records
Wider context from the report “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete , possibly due to teething problems associated with the recently introduced electronic recording system .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify police when a patient at suicide risk goes missing
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to evaluate a patient’s situation and required action after return to the ward
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him .
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to heed family warnings about a patient’s fitness for discharge
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded .
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish alternative accommodation and transition arrangements before discharge consideration
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered.
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised . In the absence of such transition infrastructure, it was premature to consider him for discharge from the section .
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a formalised mental capacity assessment before section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions .
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently consider the significance of potential farewell behaviour
Wider context from the report “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including:
a) Mr Bastock left the ward on occasions and once did not return until 5am.
b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him.
c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded.
d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered .
e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.
f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of a responsible clinician with insufficient role experience for section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks .
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made .
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update the care plan before section rescission
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated .
e. the pressure on bed availability in the Newsam Centre may have influenced the decision.
” 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 Share learning through clinical governance and remind staff to document interventions in care plans and risk assessments.
Verbatim wording from the response “Mr Bastock was assessed by an Occupational Therapist as having the functional ability to return home and appropriate input was sought to help with this, including a referral to a social worker, allocation to a CPA care co-ordinator and ongoing contact with Caring for Life. Early input from the Intensive Support Service was arranged to help facilitate successful discharge. Unfortunately, these interventions to support Mr Bastock transition back home were not documented within his care plan or risk assessment. The learning from Mr Bastock’s case will be shared with the team through the Trust’s clinical governance structure and staff will be reminded of the importance of ensuring all interventions are documented. An audit of care plans will be undertaken monthly by the ward manager and the findings will be shared with the team via the local Clinical Improvement Forums.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 medical staff training provision on mental capacity assessments.
Verbatim wording from the response “To support an improvement in relation to this area, the Trust’s Head of Mental Health Legislation, in conjunction with the Medical Director, will carry out a review of the current training provision for medical staff in relation to mental capacity assessments.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Ensure Triangle of Care principles are enacted consistently for service users and family members.
Verbatim wording from the response “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 regular ward care-planning meetings to support consistent review and updating of care plans.
Verbatim wording from the response “meetings to support a consistent team approach to care plans ensuring that care plans are reviewed and updated appropriately.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 compliance with the revised procedure’s return-interview requirements.
Verbatim wording from the response “The revised procedure will direct staff to ensure that a discussion or return interview will be held with service users upon their return to the ward following a period of unauthorised leave. This information should then inform the service user’s care plan with regards to directing staff what action to take in the event that a service user does not return from leave and future decision making with regards to agreeing leave. The Trust will audit our compliance against this aspect of the procedure in July 2022.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Undertake a Trust-wide audit of mental capacity assessments and best-interest decisions, including possible detention-rescission decisions.
Verbatim wording from the response “In January 2022, a Trust-wide audit relating to mental capacity assessments and best interest decisions will be undertaken. The Mental Health Legislation Team will review the audit tool to explore if the decision to rescind a detention can be incorporated within this audit.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Discuss amending the Responsible Clinician form to prompt documentation of mental capacity assessments when rescinding detention.
Verbatim wording from the response “A discussion will be held through the Trust’s Mental Health Legislation Operational Steering Group to amend the form completed by the Responsible Clinician when a decision to rescind the section is made, which will include a prompt for the Responsible Clinician to ensure that a mental capacity assessment is documented.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Ratify and disseminate the revised Missing Service User Procedure and adjust associated training as required.
Verbatim wording from the response “The Trust Missing Service User Procedure outlines the actions staff should take in the event a service user does not return to the ward. The Missing Service User Procedure, although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations have taken a further review of the procedure to ensure it contains the learning from this incident. The draft procedure has been circulated to stakeholders for comment and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trust wide email, and any required adjustments will also be made to any associated training.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 and share Triangle of Care principles with staff to improve family and carer involvement.
Verbatim wording from the response “We acknowledge there was a missed opportunity to involve Mr Bastock’s sister in the decision-making process and the team have subsequently reviewed and shared the principles set out in the Triangle of Care Programme. The ward manager will ensure these principles are enacted to make sure a consistent offer is given to service users and family members in line with the principles. The service has also identified a Carer Champion who will attend the monthly Triangle of Care Steering group to ensure progress against this work is shared and monitored. The Patient and Carer Experience Team also have a dedicated Carer Coordinator who supports carer champions and team/service leaders with their work relating to Triangle of Care.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement return interviews after unauthorised leave and use the information to guide care plans and future leave decisions.
Verbatim wording from the response “The revised procedure will direct staff to ensure that a discussion or return interview will be held with service users upon their return to the ward following a period of unauthorised leave. This information should then inform the service user’s care plan with regards to directing staff what action to take in the event that a service user does not return from leave and future decision making with regards to agreeing leave. The Trust will audit our compliance against this aspect of the procedure in July 2022.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 induction package to formalise explicit, proportionate support and supervision for locum medics.
Verbatim wording from the response “The core professional standards require that any new Responsible Clinician has sufficient familiarity with a patient’s past and current history to support robust decision making. To ensure the Trust learns from the sad death of Mr Bastock, the Professional Medical Lead will formalise the support and supervision arrangements that are in place for locum medics by reviewing the current induction package to ensure support and supervision arrangements are explicit and proportionate.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 and revise the Missing Service User Procedure to incorporate learning from the incident.
Verbatim wording from the response “The Trust Missing Service User Procedure outlines the actions staff should take in the event a service user does not return to the ward. The Missing Service User Procedure, although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations have taken a further review of the procedure to ensure it contains the learning from this incident. The draft procedure has been circulated to stakeholders for comment and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trust wide email, and any required adjustments will also be made to any associated training.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 care plans monthly and share development areas and good practice through local Clinical Improvement Forums.
Verbatim wording from the response “The words local system procedure outlines that care plans should be reviewed and updated weekly or if there are changes to a patient’s presentation. Mr Bastock’s care plan was updated to reflect his informal status however, no further updates were made. At the time of Mr Bastock’s admission, the Trust had transitioned to a new electronic care record system which is now robustly embedded across the organisation. From January 2022, an audit of care plans will be undertaken monthly and the findings including areas for development and good practice will be shared with the team via the local Clinical Improvement Forums. The ward has also embedded regular care planning” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Simplify the electronic care-planning document, develop supporting guidance, and provide staff support for implementing the revised care plan.
Verbatim wording from the response “Trust-wide, work is underway to simplify the existing care planning document on the electronic patient record. This will include a specifically designed in-patient care plan with a link to the FACE risk assessment. An initial draft of the care planning document will be shared through the Trust governance processes in January 2022. A guide is being developed to support staff in recording information consistently and this will include the level of engagement and agreement the service user had with each element of the care plan. Additional support will be given to staff to implement this new care plan effectively.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 clinical handover process for locum medics to support robust clinical decision-making.
Verbatim wording from the response “The Trust will also review their clinical handover process to ensure it supports robust clinical decision making when locum medics commence in post.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Rescinding detention was not premature discharge because the patient agreed to remain in hospital informally; discharge was not imminent.
Verbatim wording from the response “e. Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 A consultant psychologist was aligned to the ward and available to support clinical decision-making and care planning.
Verbatim wording from the response “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Rescinding detention did not discharge the patient or affect bed availability; discharge decisions are clinically based and not driven by resource pressures.
Verbatim wording from the response “e. The pressure on bed availability in the Newsam Centre may have influenced the decision.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ward was not without a ward manager; leadership continuity was maintained through handover and support from the outgoing manager.
Verbatim wording from the response “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
14 Oct 2021 Alexandra Jane Tolley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 10 Failure to implement a safe absconding policy while unsafe instructions continue View source Disclosure of absconding-response arrangements enabling circumvention of detention safeguards View source Failure to review wound-dressing materials before ground leave View source Availability of wound-dressing materials usable for self-harm View source Lack of documented ground-leave approval criteria and staff-grade requirements View source Lack of dynamic risk-assessment discretion for escorts responding to absconding View source Absconding instructions incompatible with the safe-detention duty under Section 2 View source Failure to determine sufficient escort numbers for ground leave View source Failure to define permissible physical interventions during escorted leave View source Failure of absconding instructions to prioritise patient safety View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexandra Jane Tolley · 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
Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.
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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a safe absconding policy while unsafe instructions continue
Wider context from the report “8. The Inquest was informed that the general policy in relation to absconding patients has been under review since Ms Tolley’s death nearly two years ago but has (understandably) been delayed during the Covid pandemic. It was said a draft revised policy was sent to West Yorkshire Police on 14 June 2021 by way of consultation, but no response has been received. In the meantime, similar instructions are still being issued to staff not to restrain or follow in some other cases . There is thus an ongoing risk of further deaths should a comparable situation arise again .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Disclosure of absconding-response arrangements enabling circumvention of detention safeguards
Wider context from the report “6. The care plan containing the staff instruction not to restrain or follow was discussed and agreed with Ms Tolley. She was thus expressly aware that if she did decide to abscond, she knew she would be able to do so. Moreover, she was explicitly told that the staff member escorting her would return to the reception area and wait for a short period in the hope Ms Tolley would return voluntarily. The implication of this was that Ms Tolley knew she had a period of grace of around 10 minutes in which to get clear of the hospital, before the police would be asked to search for her. Whilst potentially beneficial from a therapeutic perspective, such knowledge may also inform a vulnerable patient on ways in which the protection afforded by a MHA Section could be undermined . The wisdom of explaining to a patient how the hospital staff would respond to them absconding should be reviewed.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review wound-dressing materials before ground leave
Wider context from the report “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as:
(a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts. In a time critical situation this could have altered the tragic outcome;
(b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley.
(c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████ .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Availability of wound-dressing materials usable for self-harm
Wider context from the report “7. Ms Tolley was found with a ████████ made from ████████ used some time earlier to dress a self-inflicted wound . She had twice before used such ████████ as ████████ : (1) earlier the same day and (2) three days previously- 24 October. Consideration should be given to the types of ████████ used at the Becklin Centre, with a view to selecting a type which could not serve as a ████████.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documented ground-leave approval criteria and staff-grade requirements
Wider context from the report “3. The decision to permit ground leave so shortly after a ████████ incident (and only three days after a previous absconding incident) was made on a relatively informal basis. There were no documented criteria to be considered before it was approved , nor was the grade of staff required to make the decision stipulated .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of dynamic risk-assessment discretion for escorts responding to absconding
Wider context from the report “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as:
(a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts. In a time critical situation this could have altered the tragic outcome;
(b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley .
(c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absconding instructions incompatible with the safe-detention duty under Section 2
Wider context from the report “2. The absconding instructions to staff (set out above) seems incompatible with the duty to detain in order to keep safe, inherent in an order under Section 2 of the Mental Health Act 1983 when viewed in the context of a patient deemed to require such intensive monitoring.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine sufficient escort numbers for ground leave
Wider context from the report “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as:
(a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts . In a time critical situation this could have altered the tragic outcome;
(b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley.
(c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define permissible physical interventions during escorted leave
Wider context from the report “4. The instruction to staff stipulated ‘physical interventions’ will not be used to restrain Ms Tolley, yet this expression was not defined or particularised . Greater clarity might assist a staff escort (likely to be a relatively junior individual) to know whether it was permissible, for example, to put a gentle hand on Ms Tolley’s shoulder to steer her back towards the hospital.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of absconding instructions to prioritise patient safety
Wider context from the report “1. The Care Plan agreed between Ms Tolley and the team treating her, included a provision that in the event she absconded, she would neither be restrained, nor followed . Given her history and risk profile, it appeared this contingent instruction to staff regarding the risk of absconding, placed too much emphasis on her long term ability to manage her own turbulent emotions, at the expense of the imperative of keeping her safe . The priorities underlying such instructions merit further review.
” 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 Undertake a tabletop review of patients granted time off the ward to check that leave discussions occurred and were appropriately documented.
Verbatim wording from the response “Consideration for leave from the hospital ward is discussed via the MDT, it is at this meeting that the type of leave is discussed and agreed upon. This decision is based on risk, current presentation, and history in relation to what is appropriate and therapeutic for the patient at that time. The same principles would occur when discussing whether section 17 leave is appropriate. It was considered by the MDT that Ms Tolley was suitable for periods of leave within the hospital grounds as a first step on her recovery. Although ground leave had been granted by the Registered Clinician, there is an expectation that the nursing staff will dynamically review risk prior to letting a patient off the Ward.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 care plans and leave agreements, considering adjustments to least-restrictive interventions based on patients’ changing presentation and risk.
Verbatim wording from the response “In order to ensure the Trust has learnt lessons from Ms Tolley’s death, it is vital that team and clinical services review interventions described within care plans and leave agreements and consider how these interventions can be altered based on an individual’s presentation at a moment in time or following any change in the baseline mental state or any significant events. This will allow staff to use a more collaborative approach of engagement to enable them to respond to risk and also balance the risk associated with needing to potentially intervene when leave is in progress.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.
Verbatim wording from the response “The Trust has reviewed its Prevention, Management of Violence and Aggression (PMVA) training provision offered to staff regarding the role of escorting patients outside of the ward and is developing training for all staff, including bank staff. This training will be included in the initial and updated PMVA training provision. The training will be scenario and role play based and will include discussions regarding decision making related to risk whilst escorting somebody outside of the ward.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Circulate, ratify and disseminate the revised Missing Service User Procedure, making required adjustments to associated training.
Verbatim wording from the response “The draft procedure will be circulated to stakeholders for comment on the week commencing the 13 December 2021 and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trustwide email, and any required adjustments will also be made to any associated training.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Verbatim wording from the response “We will ensure that the learning from this case is communicated within our procedure – ensure that staff are provided with clear guidance when escorting patients of the action to be taken should leave start to break down or the patient leaves the member of staff.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Undertake same-day leave risk assessments, decide whether leave should be altered, and document the decision, rationale and discussion in care records.
Verbatim wording from the response “Despite a patient being granted ground leave, a further assessment should be undertaken on the day taking into consideration a number of factors including compliance with previous leave, consideration of benefits of further leave, and flexibility versus senior guidance. Additionally, the following points should be taken into consideration:” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
Verbatim wording from the response “We acknowledge that Ms Tolley had previously used her ████████. The ward team considered this along with the risk that her wound would become infected. Further learning is that the Ward Team could have requested guidance and support from the Trusts Physical Health Team to support them in considering the prevention of infection and the types of bandages that could have been used as an alternative.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 feedback on the Missing Service User Procedure to ensure it meets Trust requirements for accessibility and clarity.
Verbatim wording from the response “The Missing Service User Procedure, although led by the Trust, is jointly agreed with West Yorkshire Police. Feedback on the procedure was received from West Yorkshire Police on the 11 November 2021. Upon receipt of the regulation 28, both organisations have taken a further review of the procedure to ensure it contains the learning from the death of Ms Tolley. We are currently” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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 Physical touch was considered likely to increase distress and emotional dysregulation, so alternative support strategies were preferred.
Verbatim wording from the response “The care plan developed by the team and Ms Tolley considered the intervention of placing any form of touch to Ms Tolley. It was deemed this would increase the risk of further distress to Ms Tolley and may further increase the risk of emotional deregulation in the event of an individual placing a hand on her. However more consideration should have been given to the need to think about alternative means to support Ms Tolley, enabling her to maintain her self-control at the point of feeling distressed whilst out on leave. Alternative strategies that could have been considered at the point Ms Tolley indicated either physically or verbally that she was becoming distressed or that she was not coping with the period of escorted leave.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
16 Dec 2019 Layla Stephanie Dobson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Lack of a formalised process guiding practitioners on the appropriate route of support View source Failure to flag or reference current self-harm or suicide information to relevant decision-makers View source Failure of the mental service access process to ensure systematic consideration of each support pathway 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
Layla Stephanie Dobson · 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
Layla Stephanie Dobson, a 23-year-old student with a history of mental health issues, self-harm and suicidal ideation, was found deceased at her home on 11 March 2019. The inquest recorded that she died by hanging and reached a conclusion of suicide. Concerns included the absence of a formalised process to guide practitioners on appropriate support pathways and insufficient flagging of information about current self-harm or suicide in referral decisions.
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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formalised process guiding practitioners on the appropriate route of support
Wider context from the report “Although the PDCN considered Layla's referral, notwithstanding it does not take self-referrals to its care coordination services, the evidence provided at the inquest indicated that there was no formalised or tangible process to guide or otherwise inform practitioners as to which route of support would be appropriate for an individual .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag or reference current self-harm or suicide information to relevant decision-makers
Wider context from the report “Whilst the approach to the CMHT was decided upon and actioned, my view upon the evidence was that the area on the form relating to current self-harm/suicide is not further flagged or referenced to those taking relevant decisions and this could strengthen the scrutiny of information when deciding upon which service may be contacted.
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the mental service access process to ensure systematic consideration of each support pathway
Wider context from the report “Whilst the evidence at the inquest was clear that Layla was under the care of her GP who later assessed her mental health/risk on 8th March 2018, I am of the view that the process whereby an individual seeks to request/access mental services could be strengthened by guidance or referencing such that each pathway of support is systematically considered .
” 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 Develop guidance for referral meetings to assess suicide risk, existing support and self-referral status, recommend crisis-support steps, and record its consideration.
Verbatim wording from the response “The Personality Disorder Clinical Network service has carefully considered the matters of concerns outlined and agreed an action plan (appendix 1) at the service Clinical Governance forum held on the 30th January 2020. Firstly the service is developing guidance to further inform the decision making process with regards to referral to relevant crisis support services. The guidance will include for example:” Source location 2019-0425-Response-from-Leeds-and-York-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an automatically issued standard receipt letter for self-referrals outlining relevant crisis support services.
Verbatim wording from the response “The service will additionally change its process for responding to self-referrals by developing a standard referral receipt letter which will automatically be emailed and/or posted to service users outlining relevant crisis support services. This measure is intended to additionally ensure that service users referred to the service will always be made aware of the relevant services in the City who may be able to provide a crisis service level of response, pending the referral outcome.” Source location 2019-0425-Response-from-Leeds-and-York-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the service referral form and information leaflet with details of relevant crisis support services in Leeds.
Verbatim wording from the response “The service is also aware that there may be instances where the referral may not be considered by the referral team for up to 7 days or where direct contact with the service user was considered the most appropriate course of action and they ‘did not attend’. As such the service referral form and information leaflet (available via the LYPFT website) will be updated to provide details of relevant crisis support services in Leeds.” Source location 2019-0425-Response-from-Leeds-and-York-NHS-Trust
Open published response
2 Nov 2016 Michaela Louise Thompson · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 3 Inadequate documentation of multidisciplinary team meeting participants, outcomes and decisions View source Failure to record service call details, urgency and actions taken View source Failure to immediately communicate service calls to the involved Community Mental Health Nurse 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
Michaela Louise Thompson · 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
Michaela Louise Thompson, who had a history of depression and regular suicidal thoughts, died by self-suspension at home on 1 December 2015. Concerns included inadequate documentation of multidisciplinary team meetings and the failure to record and promptly communicate a distressing telephone call to mental health services on the morning of her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation of multidisciplinary team meeting participants, outcomes and decisions
Wider context from the report “(1) Michaela was the subject of two multi-disciplinary team meetings which were inadequately documented in the case notes . It should be clearly documented as to who was present and participating in such meetings . The identification of those involved should be clearly recorded, as should the outcome of and decisions made at such meetings .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record service call details, urgency and actions taken
Wider context from the report “(2) On the morning that Michaela Thompson died, she had telephoned Aire Court in the presence of a friend who noticed that she became anxious and upset during that brief call. There was no record kept as to the nature of the call or any information or advice given , nor was the fact of the call immediately communicated to the Community Mental Health Nurse involved. Calls to the Service should therefore be recorded, to ensure that details of the nature of the call; its urgency; and the action taken by a named individual or individuals can be clearly ascertained .
” 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 Leeds and York Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately communicate service calls to the involved Community Mental Health Nurse
Wider context from the report “(2) On the morning that Michaela Thompson died, she had telephoned Aire Court in the presence of a friend who noticed that she became anxious and upset during that brief call. There was no record kept as to the nature of the call or any information or advice given, nor was the fact of the call immediately communicated to the Community Mental Health Nurse involved . Calls to the Service should therefore be recorded, to ensure that details of the nature of the call; its urgency; and the action taken by a named individual or individuals can be clearly ascertained.
” 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 clear documentation of attendees, outcomes and decisions at multidisciplinary team meetings.
Verbatim wording from the response “I am aware of Miss Thompson’s care and sad death therefore fully accept your requirement that there should be clear documentation as to who is present at multi-disciplinary team meetings along with clear documentation of any outcomes and decisions made. It is therefore something which we will of course put in place.” Source location 2016-0392-Response-by-Leeds-and-York-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recording all calls to clinical teams may be impractical because multiple lines serve varied callers, so a feasible scope must be agreed.
Verbatim wording from the response “There are however some practical difficulties in that there are multiple phone lines coming into each team and these are used for a variety of reasons, sometimes by service users but also by other professionals and outside agencies.” Source location 2016-0392-Response-by-Leeds-and-York-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations