Concerns raised 8 Failure to share clinically important information across mental health and primary care services View source Failure to provide planned community support View source Tolerance of persistent appointment delays View source Failure to provide accessible information about care roles and contact routes View source Delays in offering psychiatric follow-up appointments View source Failure to communicate awaited community support to patients and families View source Insufficient resourcing of the psychiatric unit View source Failure to respond to non-attendance with clinical risk consideration View source See 5 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
Barry Thraves · 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
Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share clinically important information across mental health and primary care services
Wider context from the report “4. Communication between the community mental health team and other stakeholders was poor, with important information that had been identified (that Barry was depressed and not compliant with his medication) not being shared with the GP , nor were the GP or psychiatric team aware that Barry was not receiving any community support .
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide planned community support
Wider context from the report “2. Community support did not take place as planned , and the family were not even made aware that this was awaited and Barry was on the list. It was not clear what, if any, information Barry had received apart from a very brief letter of discharge that specifically did not mention the community support.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Tolerance of persistent appointment delays
Wider context from the report “3. The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time . Earlier, timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accessible information about care roles and contact routes
Wider context from the report “5. Information was not made readily available for either Barry, or the family who were trying to support him, of who was involved in his care, the extent of their role and who to contact to discuss this further or in case of any deterioration or change in presentation . This made the task of the supportive sister considerably more onerous and difficult and introduced unnecessary further delays in obtaining support for Barry at a time when his mental health was deteriorating and he was in need of urgent review.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in offering psychiatric follow-up appointments
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months ; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate awaited community support to patients and families
Wider context from the report “2. Community support did not take place as planned, and the family were not even made aware that this was awaited and Barry was on the list . It was not clear what, if any, information Barry had received apart from a very brief letter of discharge that specifically did not mention the community support .
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the psychiatric unit
Wider context from the report “3. The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time. Earlier, timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to non-attendance with clinical risk consideration
Wider context from the report “1. Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at that time .
” 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 Establish an Enablement Service providing practical support from referral while people await mental-health assessment.
Verbatim wording from the response “Adult Social Care is currently restructuring and establishing an Enablement Service to work alongside the Adult Mental Health Social Work Teams. This service is designed to be in place for 1 April 2016 and will offer adults with mental health problems practical support from the point of referral so that no one should have to wait for an assessment.” Source location 2015-0443-Response
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 Contact people awaiting case allocation fortnightly to identify changes and enable reprioritisation where necessary.
Verbatim wording from the response “In accordance with new processes, from 1 January 2016, anyone awaiting allocation will be contacted fortnightly by phone to check whether anything has changed and if the case needs re-prioritising. Team Support Workers within each team will undertake this task and report back to the Team Leader, who can then reprioritise cases as required. This process has been implemented via email from the Head of Service to Team Leaders on 15 December 2015 and will be followed up by conversations in team meetings.” Source location 2015-0443-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce written notifications for people waiting over 14 days for assessment, including contact details, support information and copies for identified carers.
Verbatim wording from the response “In order to ensure an individual, and any relevant persons, are aware of the process following a referral to Adult Social Care a new process has been developed which will be effective from 1 January 2016. The process shall be triggered where Adult Mental Health identifies that someone will need to wait more than 14 days for an assessment from the point the case is transferred to the team. Adult Mental Health Teams will write to them explaining that they have been referred for an assessment, that they will be seen as soon as possible but that they should contact the team if anything changes. Any appropriate leaflets about other support services available will be sent out at this point.” Source location 2015-0443-Response
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 next-working-day telephone and two-day written feedback from AMHP assessments to relevant GPs.
Verbatim wording from the response “It is noted that the AMHP’s report to the Coroner identifies that the psychiatrists and AMHP assessing Mr Thraves were aware that he was not compliant with his medication. It is acknowledged that it should be standard practice for information to be shared with relevant professionals, such as the GP. In order to ensure this takes place in practice the Head of Service has e-mailed all AMHPs on 15 December 2015 to remind them of the importance of feeding back to GPs following an assessment under the Mental Health Act, where the GP was not part of that assessment.” Source location 2015-0443-Response
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 Fill vacancies and improve staffing capacity to reduce assessment waiting times.
Verbatim wording from the response “Unfortunately at this time the team was under particular pressure due to long term sickness and vacancies, subsequently resulting in individuals waiting a long period of time for assessments. It is most unfortunate that this consequently impacted upon Mr Thraves and also other people awaiting assessment at that time. Fortunately, the staffing situation has now improved, vacancies are filled, and waiting times for assessment have reduced.” Source location 2015-0443-Response
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 Remind Adult Mental Health social workers to share relevant information with the full multidisciplinary team and carers.
Verbatim wording from the response “Social workers across Adult Mental Health have been reminded of the importance of feeding back to the whole multi-disciplinary team and to carers, not solely the Registered Medical Officer.” Source location 2015-0443-Response
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 concern about psychiatric follow-up falls to Leicestershire Partnership Trust, which will respond separately.
Verbatim wording from the response “This concern relates to Leicestershire Partnership Trust’s involvement with Mr Thraves and I am aware that the Trust will be responding to you on this point.” Source location 2015-0443-Response
Open published response
Concerns raised 2 Inadequate visibility at the road traffic junction View source Absence or inadequacy of filter lanes at the road traffic junction 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
Anais Chantal Thouvenot · 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
Anais Chantal Thouvenot was knocked from her bicycle by a passing vehicle at a road junction in Leicester on 9 November 2014, sustained a serious head injury, and died at Queens Medical Centre, Nottingham, on 16 November 2014. Concerns were raised about the junction’s safety, including visibility, inadequate or absent filter lanes, heavy traffic, and the road contour, with reported near misses involving cyclists.
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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility at the road traffic junction
Wider context from the report “During the course of the investigation I was made aware of specific concerns regarding the safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a member of the public ████████ who has also raised these concerns for the attention of Councillors ████████ and ████████.
The LCCG have informed me that they believe the junction to be inherently dangerous quoting a number of 'near misses' as experienced by their cycling group.
The specific concerns relate to visibility at the junction and absent or inadequate filter lanes, exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on a major cycle route into the city.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Absence or inadequacy of filter lanes at the road traffic junction
Wider context from the report “During the course of the investigation I was made aware of specific concerns regarding the safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a member of the public ████████ who has also raised these concerns for the attention of Councillors ████████ and ████████.
The LCCG have informed me that they believe the junction to be inherently dangerous quoting a number of 'near misses' as experienced by their cycling group.
The specific concerns relate to visibility at the junction and absent or inadequate filter lanes , exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on a major cycle route into the city.
” Open source report
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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 junction design, signalling and gradient comply with applicable design requirements and provide adequate safety controls.
Verbatim wording from the response “The junction design and signalling arrangements have taken account of the Design Manual for Roads and Bridges (Volume 6, Section 2, Part 3 - TD 50/04, The Geometric Layout of Signal Controlled Junction and Signalised Roundabouts). As such, constraints such as existing road geometry, buildings and availability of land have been considered in accordance with TD50/04 and junction inter-visibility has been maximised.” Source location 2015-0110-Response-by-Leicester-City-Council
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 Existing road geometry makes providing both cycle and all-vehicle lanes difficult, while removing the right-turn lane could harm traffic flow and cyclist safety.
Verbatim wording from the response “The existing road geometry at the junction renders the provision of both cycle and all-vehicle lanes difficult. In addition, loss of the right turn lane into King Street may not be of any benefit to cyclists, but could cause problems with traffic flow through the junction, adding to congestion. It may also result in inappropriate driver behaviour which could have a detrimental effect on the safety of cyclists through the junction.” Source location 2015-0110-Response-by-Leicester-City-Council
Open published response
Concerns raised 4 Lack of standards and objectively assessed qualifications for assessing stray dogs’ suitability for re-homing View source Lack of standards for assessing potential applicants’ suitability and home circumstances when re-homing a dog View source Lack of independent verification of kennels’ dog re-homing policies and their implementation View source Lack of national or local standards for judging stray dog re-homing policies 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
Lexi Branson · 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
Lexi Branson, aged 4¾ years, died after a dog attacked her in the living room of her home, causing extensive neck and facial injuries and preventing breathing. The report identified concerns about the absence of national or local standards for re-homing stray dogs, assessing dogs and applicants, and independently verifying kennel policies and their implementation.
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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of standards and objectively assessed qualifications for assessing stray dogs’ suitability for re-homing
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments ;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of standards for assessing potential applicants’ suitability and home circumstances when re-homing a dog
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog .
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of independent verification of kennels’ dog re-homing policies and their implementation
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation .
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national or local standards for judging stray dog re-homing policies
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged ;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” Open source report
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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 raised issues are potentially wider than the Council’s remit, particularly without national standards governing organisations providing dog rehoming services.
Verbatim wording from the response “The four issues you have raised are potentially wider than matters within the remit of Leicester City Council and accordingly in the absence of national standards it is difficult to understand how Leicester City Council could contribute. Even if any national standards were drafted, we can see no way in which any of the usually charitable small organisations could be compelled to agree to those standards if issued as guidance only. The very disparate and varied nature of the sort of bodies which provide that service across the UK, aside from legal obligations, possibly explains why each different organisation may adopt its own individual rehoming standards. In part this also covers the fourth “concern” you have raised in your report.” Source location Response from Leicester City Council
Open published response
Concerns raised 3 Delayed lines of sight between opposing traffic flows View source Insufficient separation between the junction, lane merger and joining traffic flows View source Acute rightward movement of the inner lane 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
Paul Millis · 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
Paul Millis died after riding his motorbike through the junction of Troon Way and Nicklaus Road in Leicester and colliding head-on with a car on 3 December 2013. The principal concerns were the short distances over which two lanes merged and opposing traffic joined, potentially causing delayed lines of sight, together with the acute movement of one lane into the carriageway.
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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Delayed lines of sight between opposing traffic flows
Wider context from the report “1. The merger of the 2 lanes occurs within a very short distance of the junction: approximately 35 metres. The process of merger by the 2 lanes is that the traffic moves in opposite directions – i.e. the inner lane moves to the right, thereby avoiding the verge, and the outer lane is directed by arrows to the left.
2. The westbound carriageway merges as described, and then as a single lane continues to the right until it straightens out into a single carriageway adjoining the eastbound traffic. The joining of the two flows of traffic occurs only 90 metres after the junction described above.
3. The situation described in 2 above means that any vehicle either behind another vehicle, or even beside it, will have a very delayed line of sight for traffic travelling eastbound, and likewise applies to eastbound traffic’s line of sight to a vehicle behind a first vehicle travelling westbound . As stated all of this movement of traffic is occurring in a very short distance and time.
4. It would appear that when the inner lane makes its sudden, very acute move to the right, that there is vacant verge area that would have allowed the lane to move less acutely.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient separation between the junction, lane merger and joining traffic flows
Wider context from the report “1. The merger of the 2 lanes occurs within a very short distance of the junction: approximately 35 metres. The process of merger by the 2 lanes is that the traffic moves in opposite directions – i.e. the inner lane moves to the right, thereby avoiding the verge, and the outer lane is directed by arrows to the left.
2. The westbound carriageway merges as described, and then as a single lane continues to the right until it straightens out into a single carriageway adjoining the eastbound traffic. The joining of the two flows of traffic occurs only 90 metres after the junction described above.
3. The situation described in 2 above means that any vehicle either behind another vehicle, or even beside it, will have a very delayed line of sight for traffic travelling eastbound, and likewise applies to eastbound traffic’s line of sight to a vehicle behind a first vehicle travelling westbound. As stated all of this movement of traffic is occurring in a very short distance and time.
4. It would appear that when the inner lane makes its sudden, very acute move to the right, that there is vacant verge area that would have allowed the lane to move less acutely.
” 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 Leicester City Council; that does not assign responsibility.
PFD Monitor interpretation Acute rightward movement of the inner lane
Wider context from the report “1. The merger of the 2 lanes occurs within a very short distance of the junction: approximately 35 metres. The process of merger by the 2 lanes is that the traffic moves in opposite directions – i.e. the inner lane moves to the right, thereby avoiding the verge, and the outer lane is directed by arrows to the left.
2. The westbound carriageway merges as described, and then as a single lane continues to the right until it straightens out into a single carriageway adjoining the eastbound traffic. The joining of the two flows of traffic occurs only 90 metres after the junction described above.
3. The situation described in 2 above means that any vehicle either behind another vehicle, or even beside it, will have a very delayed line of sight for traffic travelling eastbound, and likewise applies to eastbound traffic’s line of sight to a vehicle behind a first vehicle travelling westbound. As stated all of this movement of traffic is occurring in a very short distance and time.
4. It would appear that when the inner lane makes its sudden, very acute move to the right , that there is vacant verge area that would have allowed the lane to move less acutely .
” 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 fourth road safety audit after 12 months, reviewing serious accident records and causes and making recommendations on potential design and safety issues.
Verbatim wording from the response “A fourth safety audit is required to be undertaken after 12 months. This will take into account records of accidents and make recommendations for any changes where significant levels of risk to users are identified.” Source location 2014-0176-Response
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 junction design complies with mandatory standards, and the merge length, alignment, visibility and traffic arrangement are considered reasonable and customary.
Verbatim wording from the response “I can confirm and provide assurance that the highway design does comply with relevant standards, including the Design Manual for Roads and Bridges (Volume 6, Section 2, Part 3 - TD 50/04). I can also confirm that although the A563 Troon Way is not a trunk road, the higher design standards for trunk roads have been applied during the design process. In particular, the mandatory standards relating to visibility on approach to junctions have been met.” Source location 2014-0176-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations