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
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Monitor handover-process compliance and effectiveness through audits and feedback mechanisms.
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Action
Ensure CRISS shift coordinators bring Oasis handover information to each locality’s daily multidisciplinary team meeting.
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Action
Use a standardised daily handover template to capture clinical information, reviews, tasks, incidents, MDT comments and required follow-up.
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Action
Explore Oasis staff access to LYPFT’s electronic patient record and discuss the proposal through the operations meeting.
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Action
Record handover details and required actions in Oasis’s own system.
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Action
Hold a daily Oasis–CRISS huddle to discuss handover information and address immediate actions and queries.
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Action
Provide training on the handover sheet, including each organisation’s roles and responsibilities.
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Action
Add Oasis handover notes, MDT discussions and required actions to LYPFT care records.
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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 Survivor-Led Crisis Service; 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.
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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 Monitor handover-process compliance and effectiveness through audits and feedback mechanisms.
Verbatim wording from the response “5. Training and Governance” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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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 CRISS shift coordinators bring Oasis handover information to each locality’s daily multidisciplinary team meeting.
Verbatim wording from the response “2. Multidisciplinary Review Meetings” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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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 a standardised daily handover template to capture clinical information, reviews, tasks, incidents, MDT comments and required follow-up.
Verbatim wording from the response “1. Standardised Daily Handover and implementation of daily ‘huddle’ meeting” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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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 Explore Oasis staff access to LYPFT’s electronic patient record and discuss the proposal through the operations meeting.
Verbatim wording from the response “In addition to the above, the CRISS team at LYPFT and Oasis staff are exploring the possibility of Oasis staff having access to LYPFT’s electronic patient record. This will be taken for further discussion through the operations meeting (described below).” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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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 Record handover details and required actions in Oasis’s own system.
Verbatim wording from the response “3. Documentation improvements” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a daily Oasis–CRISS huddle to discuss handover information and address immediate actions and queries.
Verbatim wording from the response “Once completed, the handover sheet is emailed to the appropriate LYPFT Crisis Resolution Intensive Support Service (CRISS) team. There are three locality teams East, South, and West, and the handover is sent to the corresponding area in which the individual is currently receiving care. The shift coordinator within the CRISS team is responsible for accessing this information and ensuring this is taken for discussion in the daily ‘huddle’ meeting as described below.” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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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 training on the handover sheet, including each organisation’s roles and responsibilities.
Verbatim wording from the response “5. Training and Governance” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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 Add Oasis handover notes, MDT discussions and required actions to LYPFT care records.
Verbatim wording from the response “• LYPFT adds Oasis handover notes to the patient’s LYPFT care record as well as a full record of the MDT discussion and any required action.” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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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 Existing referral, admission, joint review, interface, operations and governance processes provide formal communication and risk-management arrangements.
Verbatim wording from the response “We would also like to take this opportunity to describe the escalation processes and monitoring we currently have in place to ensure formal communication, risk management, and information sharing for patients admitted to the respite facility:” Source location Response from Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor-Led Crisis Service
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations