Concerns raised 3 Failure to use carers' views to inform follow-up safety plans View source Lack of clear staff guidance on using alternative-format evidence View source Lack of checks that carers are equipped to support patients at home 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
James Ralph COCHRANE · 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
James Ralph Cochrane, who had schizoaffective disorder with fluctuating mood and psychosis, died on 17 November 2023 after jumping from an overbridge into the carriageway and being struck by a vehicle. The report raises concerns about how carers’ views and video evidence are considered and used in safety planning, and about the support provided to carers assisting mental health patients at home.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use carers' views to inform follow-up safety plans
Wider context from the report “The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work and training has been done to encourage staff to listen to carers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear staff guidance on using alternative-format evidence
Wider context from the report “The extent to which staff should consider evidence provided in alternative formats such as video evidence. It was acknowledged during the inquest that recordings from mobile phones can provide helpful evidence of a patients presentation. I understood that a question had been raised internally at the trust as to what extent such evidence should be viewed, and used to inform decisions, however a final decision has not been made. Given the use of mobile phones etc in modern society, I am concerned that there is no clear guidance to staff as to how such evidence should be used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checks that carers are equipped to support patients at home
Wider context from the report “Support offered to carers who are providing support to mental health patients. It was acknowledged that carers have an important role. I heard evidence regarding mechanisms that have been put in place via systmone to record carers views, but it is unclear as to what checks are in place to ensure that carers are equipped to support patients in their home environment .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Electronic Health Records Policy to reflect guidance on viewing patient videos taken by family members, carers or friends.
Verbatim wording from the response “Also, the Trust’s Electronic Health Records Policy (including Record Keeping Management) will be updated to reflect the One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers or friends will be updated by the end of November 2025.” Source location Response from NHS Leicestershire Partnership 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 Share the data-privacy brief on viewing patient videos with all mental health teams by the end of November 2025.
Verbatim wording from the response “In September, our Data Privacy Team created a One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers, or friends (Appendix 3) which provides advice and guidance to support our clinical staff who see patients in the community. This will be shared locally with all mental health teams by the end of November 2025 and was shared in trust-wide communication on 26 September 2025.” Source location Response from NHS Leicestershire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the Carers Trust Triangle of Care framework through community mental health team self-assessments, benchmarking and identified improvement actions.
Verbatim wording from the response “In addition, Leicestershire Partnership NHS Trust is rolling out the nationally recognised Carers Trust Triangle of Care (TOC) framework and currently community mental health teams are completing self-assessments (due 31 October 2025), which include benchmarking current practice and identifying any actions needed to include carers throughout a patient’s journey of care. The Trust also follows the Culture of Care programme and implements guidance embedding the 12 Culture of Care standards. These commitments are interlinked and fundamental to carers’ involvement as an integral aspect of patient care. The Trust has also embedded the Patient and Carer Race Equality Framework (PCREF) that supports our services with the delivery of high standards of care via simple and effective patient and carer feedback mechanisms and that ultimately minimises racial inequalities.” Source location Response from NHS Leicestershire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document carers’ views and support needs in electronic care and safety plans, making them available to clinicians and using them in care decisions.
Verbatim wording from the response “Response:
The Trust acknowledges the importance of listening and capturing carers views during assessment and routine follow ups and therefore has ensured that these views can be documented (with consent” Source location Response from NHS Leicestershire Partnership NHS Trust
Open published response
×
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 Carers needing additional support will be referred to social care for a carer’s assessment.
Verbatim wording from the response “We acknowledge the important (and sometimes challenging) role that carers have when supporting patients in their home environment. When staff attend patients in the community, the Trust advises staff to ask carers if they require support mechanisms they have in place in light of their own role as carer. This is reflected in the nursing intervention plan (Appendix 1) and the collaborative care plan (Appendix 2) to ensure documentation of the carer’s views and responses. We hold the view that where a carer identifies the need for additional support to look after their loved ones and in particular, due to the presenting circumstances of the patient, the Trust would refer the carer to social care for a carer’s assessment.” Source location Response from NHS Leicestershire Partnership NHS Trust
Open published response
Concerns raised 9 Failure to embed serious incident learning and changes in frontline practice View source Failure to document MDT meeting decision making and risk downgrading rationale View source Failure to provide a requested medic review View source Failure to link identified serious incident failings to action-plan work View source Lack of planned post-discharge support View source Failure to use accurate medical record information in MDT decision making View source Failure to revisit working diagnoses and explore potential severe depressive disorder View source Failure to robustly consider red-flag risk factors in risk assessments View source Failure of serious incident investigations to robustly and critically examine all relevant care issues View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Run a rapid improvement programme using quality-improvement methodology to identify improvements to the serious-incident investigation and reporting process.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024. View source
Action
Include a senior nurse clinician, medical colleagues and crisis-service members in MDT meetings to oversee and support the process.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2024. View source
Action
Implement the revised MDT template and pre-MDT referral process to clarify referrals and capture clinical information, decisions, actions and owners.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2024. View source
Action
Present the risk-assessment review outcomes to the Urgent Care Quality and Safety Meeting to inform required changes.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2024. View source
Action
Revise the Crisis Resolution Home Treatment Team SOP to clarify MDT processes and when medical review should be considered or offered, and disseminate it with staff confirmation of understanding.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2024. View source
Action
Conduct monthly audits of MDT processes and documentation, share feedback with staff, review outcomes through quality governance, and undertake additional six-month senior scrutiny.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2024. View source
Action
Complete the review of the clinical risk-assessment competency framework and audit tool to strengthen monitoring of risk-assessment and formulation documentation.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2024. View source
Action
Review causal factors and deliver additional training to the team on reading clinical records before Safe and Well calls and clinical decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024. View source
Action
Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024. View source
Action
Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024. View source
Action
Deliver additional training and reflection sessions for the nurse and her line manager regarding the case context.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2024. View source See 8 more actions
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AI-generated summary
Christopher Henrik LARSEN · 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
Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed serious incident learning and changes in frontline practice
Wider context from the report “4. The Serious Investigation and Reporting Process at LPT
I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust.
The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan.
There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation.
Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff .
I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients, further, I have concerns about the ability of the Trust to embed changes and learning .
This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document MDT meeting decision making and risk downgrading rationale
Wider context from the report “1. Multi-Disciplinary Team (“MDT”) Meetings
I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen.
It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information . The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients.
The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information.
There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.”
At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a requested medic review
Wider context from the report “1. Multi-Disciplinary Team (“MDT”) Meetings
I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen.
It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients.
The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information.
There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic .”
At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to link identified serious incident failings to action-plan work
Wider context from the report “4. The Serious Investigation and Reporting Process at LPT
I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust.
The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan .
There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation.
Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff.
I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients, further, I have concerns about the ability of the Trust to embed changes and learning.
This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of planned post-discharge support
Wider context from the report “3. Discharge
Mr Larsen was discharged from the care of LPT on 3 December 2022, there was no planned support for Mr Larsen post-discharge other than some counselling which was due to start three weeks later.
The Trust’s SI report states that it is “unclear why it was felt the risks had subsided by the time of discharge on 3.12.2022” and that Mr Larsen had the “presence of ample markers for high risk of completed suicide” yet he was discharged back to the care of his GP and into a lacuna of care with no pre-arranged support other than counselling which would not commence for three weeks .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use accurate medical record information in MDT decision making
Wider context from the report “1. Multi-Disciplinary Team (“MDT”) Meetings
I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen.
It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients.
The MDT meeting either misread or misunderstood Mr Larsen’s medical records . The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information .
There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.”
At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to revisit working diagnoses and explore potential severe depressive disorder
Wider context from the report “1. Multi-Disciplinary Team (“MDT”) Meetings
I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen.
It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients.
The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information.
There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.”
At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly consider red-flag risk factors in risk assessments
Wider context from the report “2. Risk assessments
At his initial triage (undertaken by the Central Access Point) Mr Larsen was deemed to be high risk. At a later MDT meeting Mr Larsen was deemed to be low risk. It is not possible to explore the rationale behind the downgrading of Mr Larsen’s risk to low because there is no documentation about the decision making.
The Trust’s SI report identified the fact that several “red flag” risk factors which applied to Mr Larsen were not “robustly considered” when assessing Mr Larsen’s risk .
The Trust’s SI report states that it was “unclear why it was felt the risks had subsided by the time of discharge on 3.12.2022”.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to robustly and critically examine all relevant care issues
Wider context from the report “4. The Serious Investigation and Reporting Process at LPT
I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust.
The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan.
There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation .
Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff.
I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients , further, I have concerns about the ability of the Trust to embed changes and learning.
This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a rapid improvement programme using quality-improvement methodology to identify improvements to the serious-incident investigation and reporting process.
Verbatim wording from the response “We take learning form serious incidents very seriously and have taken on board feedback provided relating to the processes within the Trust. All serious incident reports are reviewed by the Medical Director and Chief Nurse to ensure that they provide a critical analysis and investigation of the care provided to patients. We also recognise that the transition to the new National Patient Safety Incident Response Framework (PSIRF) has taken time to embed. Feedback from the new PSIRF process has been positive from families and clinicians. In order to make the process more robust a rapid improvement programme is underway to utilise quality improvement methodology to identify any improvements which can be made to the process.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include a senior nurse clinician, medical colleagues and crisis-service members in MDT meetings to oversee and support the process.
Verbatim wording from the response “The MDT meeting attendance has also been reviewed to include a senior nurse clinician to oversee the process along with medical colleagues and other members of the crisis service. The MDT meeting will utilise the information within the pre-MDT template and the most recent Core assessment, Risk assessment and the contemporaneous clinical notes to inform the clinical discussions. The discussions within the MDT will be captured in real-time in the MDT template and the outcomes, decisions and actions agreed and documented; the MDT template forms part of the patient notes and will be immediately available.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised MDT template and pre-MDT referral process to clarify referrals and capture clinical information, decisions, actions and owners.
Verbatim wording from the response “As part of immediate learning and action taken relating to the concerns you have raised directly about the MDT meeting and documentation, we have reviewed and made substantial changes to the MDT template to be used for MDT meetings [Appendix 1]. In addition, after engagement with clinical staff and extended reflection on the death of Christopher Larsen, we have also implemented a process to provide further clarity on the reason for referral into the MDT meeting via pre-MDT sections to be completed on the MDT template. This template will be completed by the clinician who had the last clinical contact with the patient prior to the MDT meeting. The information captured in this template and the reason for the referral into the MDT meeting will be discussed with the patient at this clinical contact and will support the information captured within the patient’s notes and risk assessment.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present the risk-assessment review outcomes to the Urgent Care Quality and Safety Meeting to inform required changes.
Verbatim wording from the response “As the assessment of risk is a key component to the effectiveness of the clinicians working within the Crisis team, the Trust is completing a review of our competency framework and the audit tool to support the monitoring of robust documentation of risk assessment/formulation. This review was completed on 02 August 2024. The outcomes of the review will be presented to the Urgent Care Quality and Safety Meeting on the 22 August 2024 to inform any required changes.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Crisis Resolution Home Treatment Team SOP to clarify MDT processes and when medical review should be considered or offered, and disseminate it with staff confirmation of understanding.
Verbatim wording from the response “The Crisis Resolution Home Treatment Team Standard Operating Procedure (SOP) [Appendix 2] has also been reviewed and amended to clearly explain all these processes for our staff and includes specific guidance on how to identify when a medical review should be considered/offered as this is not required for all patients. The revised SOP was agreed on 24 July 2024 and was circulated to all staff via email on 25 July 2024; it was also shared in team meetings which take place weekly. Staff have been required to sign a confirmation that they have read and understand the SOP and the new process.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly audits of MDT processes and documentation, share feedback with staff, review outcomes through quality governance, and undertake additional six-month senior scrutiny.
Verbatim wording from the response “To provide assurance to the Directorate senior clinical team, audits will be undertaken monthly to ensure the processes and documents are being completed fully and to the standards expected. Feedback from the audits will be shared with the staff involved via their weekly meeting to ensure they are aware of areas requiring improvement. The outcomes of the audit will be reviewed within the Directorate Quality and Safety Governance meeting, with evidence of learning shared; this will be monitored monthly. In addition, the Chief Nurse and Medical Director will review the audits, sample of decisions and outcomes of the new process in six months to provide additional assurance and scrutiny.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the review of the clinical risk-assessment competency framework and audit tool to strengthen monitoring of risk-assessment and formulation documentation.
Verbatim wording from the response “As the assessment of risk is a key component to the effectiveness of the clinicians working within the Crisis team, the Trust is completing a review of our competency framework and the audit tool to support the monitoring of robust documentation of risk assessment/formulation. This review was completed on 02 August 2024. The outcomes of the review will be presented to the Urgent Care Quality and Safety Meeting on the 22 August 2024 to inform any required changes.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review causal factors and deliver additional training to the team on reading clinical records before Safe and Well calls and clinical decisions.
Verbatim wording from the response “We understand and recognise that this has occurred previously and as part of our ongoing learning we are reviewing all causal factors whilst reminding clinicians of the importance of reviewing medical records before taking any clinical decisions. Additional training has been delivered to this team regarding professional responsibility for reading a clinical record before making calls and taking clinical decisions.” Source location Response from Leicestershire Partnership NHS (1)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.
Verbatim wording from the response “As a learning point from the feedback provided, we are reviewing the layout of the safe and well template to ensure that this is in a format which makes this as easy as possible for call takers to review the information and assess risk and capture information from the call. The new template will be co-produced with staff and will be signed off by the Information Management and Technology (IM&T) Clinical Safety and Improvement Group.” Source location Response from Leicestershire Partnership NHS (1)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.
Verbatim wording from the response “Training and team meetings are important vehicles for us in reminding people of the importance of this, and we are also formalising this by updating the Central Access Point Standard Operating Procedure (SOP) to be explicit that it is the clinician’s responsibility to manage their own allocated work for the shift, look through the referrals having considered the patient record and prioritise the triage calls on risk, urgency and patient availability.” Source location Response from Leicestershire Partnership NHS (1)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver additional training and reflection sessions for the nurse and her line manager regarding the case context.
Verbatim wording from the response “Regular training, clinical supervision and reflection sessions take place routinely for clinical staff, however following this feedback, additional training and reflection sessions were undertaken with the nurse, and the line manager of the nurse to fully understand the context in this case. A full investigation into the nurses’ practice is underway internally; this will include consideration of the appropriateness of an NMC referral in line with Trust processes. In the meantime, the nurse is restricted from undertaking any nursing shifts within community services within the Trust or as a practicing lone qualified member of staff in an inpatient setting until the investigation concludes.” Source location Response from Leicestershire Partnership NHS (1)
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 Red-flag risk factors alone do not establish likelihood of self-harm or suicide; risk decisions should be based on clinical formulation.
Verbatim wording from the response “The risk assessment undertaken by the clinician presenting a case to the MDT, forms part of the information considered by the MDT in accordance with NICE [NG225] guidelines which state that decisions about care should not be made based on risk assessment tools and should be based on clinical formulation. Additionally, they state that the aforementioned 'red flag' risk factors alone do not indicate the likelihood of self-harm or suicide amongst the patients under crisis (who by the nature of their presentation, would all be deemed at a higher level of risk than those in the general population). The MDT considers the clinicians assessment of risk at the time of assessment. When the outcome of the MDT is shared with the patient, it offers a further opportunity for the clinician to assess whether the risk presentation has changed from the previous assessment.” Source location Response from Leicestershire Partnership NHS (2)
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 Discharge to primary care is considered appropriate for many patients when supported by a collaboratively formulated crisis and contingency plan with 24-hour access.
Verbatim wording from the response “The Crisis Resolution Home Treatment Team is a short-term, needs-based intervention service whose primary role is to mitigate the requirement for inpatient admission to an acute mental health hospital setting. Patients are referred into the service for intensive home treatment from a variety of different settings, including both primary and secondary care. For a substantial number of patients who have received care from the team, a referral into secondary care is not clinically appropriate or indicated. Many patients are subsequently discharged back to primary care following the formulation of a clear crisis and contingency plan which is formulated in collaboration with the patient (and carers where applicable).” Source location Response from Leicestershire Partnership NHS (2)
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 Medical review is not required for every patient; the revised SOP provides guidance on when medical review should be considered or offered.
Verbatim wording from the response “The Crisis Resolution Home Treatment Team Standard Operating Procedure (SOP) [Appendix 2] has also been reviewed and amended to clearly explain all these processes for our staff and includes specific guidance on how to identify when a medical review should be considered/offered as this is not required for all patients. The revised SOP was agreed on 24 July 2024 and was circulated to all staff via email on 25 July 2024; it was also shared in team meetings which take place weekly. Staff have been required to sign a confirmation that they have read and understand the SOP and the new process.” Source location Response from Leicestershire Partnership NHS (2)
Open published response
Concerns raised 2 Failure of the Crisis Team procedure to require obtaining relevant risk information from other agencies at assessment View source Lack of first aid training for accommodation staff 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
Lily Precious JAHANY · 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
Lily Precious Jahany was an 18-year-old medical student with a complex mental health history who died after taking increased doses of medication and suspending herself by a ligature in her student accommodation. The report identified concerns about the lack of first-aid training among student accommodation staff and failures to obtain and share relevant mental-health risk information, including from private clinicians.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Crisis Team procedure to require obtaining relevant risk information from other agencies at assessment
Wider context from the report “(2) I have spent a lot of time in this inquest investigating the information which was known about Lily, about her mental health and who had access to what information in the context of assessing her risk.
In September of 2023, Miss Evans, Assistant Coroner sitting within the Rutland and North Leicestershire jurisdiction heard an inquest concerning a student at Loughborough University. Similar to Lily’s case he was under the care of a private psychiatrist elsewhere in the country where he had lived prior to attending university. As a result of concerns in that case (his death occurring 1 year before Lily’) around lack of contact by the Crisis Team at the time of assessment or otherwise with the private psychiatrist, the Coroner wrote to the Leicestershire Partnership Trust to share her concerns.
The Trust referenced the Crisis Team Standard Operating procedure in the inquest in September 2023, the Coroner was concerned about the level of awareness that staff members had of any expectation required of them set within that procedure to seek information from other agencies.
I now have sight of the Crisis Team Standard Operating Procedure. It sets out the keyworker responsibilities. The section is drafted presupposing that patients are receiving care and treatment from the Crisis Team and only at that point does the responsibility for seeking relevant information from other agencies kick in . Furthermore the emphasis upon that requirement is limited to one line which reads ‘responsibility for referrals and liaising with other agencies involved’. That is anything but clear as to any expectation upon staff to ensure they have at their disposal all of the relevant risk information at the time of making that assessment ; nor does it in my view set out any expectation upon staff to proactively
make contact with treating clinicians in the private sector to gain information . It would not capture situations such as Lily’s, who was discharged from the Crisis Team after an 1 hour assessment and therefore was not under their care and treatment , having found a failure to obtain all relevant information pertinent to her risk in assessing that risk.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of first aid training for accommodation staff
Wider context from the report “(1) Lily resided at student accommodation provided by Student Roost. They describe themselves on their website as ‘a student accommodation provider who puts your wellbeing first. Our aim is to provide the very best experience for you to make the most of student living.’
Since they were established in 2017, Student Roost has grown to offer 50+ properties across the UK.
Student Roost run a 24/7 service including a Night Owl Service which is an excellent idea and provides a 24 hour service to help students with everything from loosing their keys, broken taps, but also their wellbeing.
During the course of hearing evidence, it is evident that all of Lily’s extreme acts of self-harm took place at her student accommodation. She took at least 3 overdoses and also carried out 2 acts of ligating which she had to be either untied or cut down from. One of those I heard required CPR. I am therefore surprised to learn that no staff (certainly in the 6 properties offering accommodation within Leicester) had first aid training and that it isn’t mandatory, such that no staff are trained by Student Roost in first aid . It transpires therefore that any immediate first aid provided to Lily was provided by those who fortuitously had that training from other organisations before they joined Student Roost. In the context of this case but also wider than that, members of the accommodation staff could potentially be the first people at the scene of a situation requiring first aid and then emergency services ; where death may occur the fact therefore that they receive no training concerns me.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Crisis Resolution Home Treatment Team and Mental Health Central Access Point procedures to clarify information-gathering expectations and actions when key professionals cannot be contacted.
Verbatim wording from the response “We have undertaken a full review of the Crisis Resolution Home Treatment Team Standard Operating Procedure and the Mental Health Central Access Point Standard Operating Procedure (SOP). These SOP’s have been updated to explicitly clarify the professional expectations regarding information gathering by liaising with key professionals which includes private providers and psychiatrists. The SOP’s also include a process for what to do when we are unable to contact key professionals including private sector care providers.” Source location 2024-0273 Response from Leicestershire Partnership 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 Student Roost is responsible for addressing the first matter of concern; the Trust will respond only to the second matter relevant to it.
Verbatim wording from the response “In your Report, you raised two Matters of Concern. The first of these Matters of Concern is better addressed by Student Roost who no doubt will respond direct. I will therefore respond to the second matter of concern which is relevant to the Trust.” Source location 2024-0273 Response from Leicestershire Partnership Trust
Open published response
Concerns raised 4 Failure to review patients’ records before CRISIS team MDT meetings View source Failure of Serious Incident investigations to provide robust critical analysis and identify learning for patient safety View source Failure of CRISIS team MDT meetings to use accurate patient medication information when agreeing treatment plans View source Failure to complete and retain sufficiently detailed MDT discussion documentation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marie ZARINS · 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
Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients’ records before CRISIS team MDT meetings
Wider context from the report “1) I am concerned about the CRISIS team MDT meetings and their functionality. It is difficult to understand how a meeting attended by around 7 people agreed a treatment plan which was based upon incorrect information relating to the patient’s medication status. This is particularly difficult to understand when the correct medication status is clearly documented in the patient’s core assessment paperwork (which was completed by the Liaison Team on 22 November 2021 and sent to the CRISIS Team).
An LPT staff member was candid about the fact that he did not have enough time to review patients’ records before the MDT meetings , this is a grave concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident investigations to provide robust critical analysis and identify learning for patient safety
Wider context from the report “3) I remain gravely concerned about the inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust.
The Serious Incident Investigation failed to identify the errors in the care provided to Miss Zarins making the use of the process somewhat otiose in this case. The failure to properly investigate led to the wholly untenable situation where errors in care were uncovered for the first time at inquest , which took place some 20 months after the date of death (due to witness availability).
I am concerned that the lack of robust critical analysis and investigation of the care provided to Miss Zarins before her death has caused a delay to, and led to missed opportunities (for some staff) to learn lessons that are vital to patient safety .
My concerns relating to the inadequacy of the Trust Serious Incident Investigations and the risks related to that go far beyond just the care provided by the CRISIS Team. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of CRISIS team MDT meetings to use accurate patient medication information when agreeing treatment plans
Wider context from the report “1) I am concerned about the CRISIS team MDT meetings and their functionality. It is difficult to understand how a meeting attended by around 7 people agreed a treatment plan which was based upon incorrect information relating to the patient’s medication status . This is particularly difficult to understand when the correct medication status is clearly documented in the patient’s core assessment paperwork (which was completed by the Liaison Team on 22 November 2021 and sent to the CRISIS Team).
An LPT staff member was candid about the fact that he did not have enough time to review patients’ records before the MDT meetings, this is a grave concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and retain sufficiently detailed MDT discussion documentation
Wider context from the report “2) I remain concerned about both the standard of documentation and lack of documentation relating to the discussion of Miss Zarins at the two MDT meetings . The Trust were only able to provide me with documentation relating to one of the two MDT meetings. That documentation is incorrectly completed and lacks detail . In particular, there is no detail about medication despite there being a specific box within which to document this .
This problem of poor and/or missing documentation is not a risk that is limited to the CRISIS Team, it is one that could have ramifications not only across the Trust but across all of the bodies who come together to provide care for patients.
” 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 Obtain accreditation for the Trust’s Serious Incident investigation and review processes through the Royal College of Psychiatrists’ accreditation network.
Verbatim wording from the response “Earlier this year, the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN) awarded accreditation to the Trust for our Serious Incident (SI) processes. This is a national quality improvement and accreditation network for Mental Health Trusts. This accreditation concentrates on the quality of investigations and reviews and ensures processes are in place to work meaningfully with patients, their families and staff equally to identify learning. We were awarded this accreditation in recognition of the high standard of SI reporting undertaken by the Trust in 2023. We believe that this demonstrates the pace and extent of improvement undertaken since the time of the SI report in relation to Miss Zarin’s death. We continue to build on this as we transition towards the Patient Safety Incident Response Framework.” Source location Response from Leicestershire Partnership NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the original Serious Incident report with input from the previously unavailable Locum Consultant.
Verbatim wording from the response “As agreed during the inquest, contact details were shared with the Trust and the Locum Consultant is now engaging in our review of the original SI report.” Source location Response from Leicestershire Partnership 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 Review Crisis Team MDT processes and improve the functionality of recording and documenting MDT meeting notes through a quality improvement programme.
Verbatim wording from the response “In order to learn and improve, the Trust has actioned a quality improvement programme which will review our MDT processes and improve the functionality of the recording and documenting of MDT meeting notes. This is focussed within the Crisis Team initially and will be further rolled out to Community Mental Health Teams and inpatient areas. We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.” Source location Response from Leicestershire Partnership 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 Current serious incident reporting processes meet a high standard, as demonstrated by national accreditation and subsequent improvement since the case investigation.
Verbatim wording from the response “Earlier this year, the Royal College of Psychiatrists’ Serious Incident Review Accreditation Network (SIRAN) awarded accreditation to the Trust for our Serious Incident (SI) processes. This is a national quality improvement and accreditation network for Mental Health Trusts. This accreditation concentrates on the quality of investigations and reviews and ensures processes are in place to work meaningfully with patients, their families and staff equally to identify learning. We were awarded this accreditation in recognition of the high standard of SI reporting undertaken by the Trust in 2023. We believe that this demonstrates the pace and extent of improvement undertaken since the time of the SI report in relation to Miss Zarin’s death. We continue to build on this as we transition towards the Patient Safety Incident Response Framework.” Source location Response from Leicestershire Partnership NHS Trust
Open published response
Concerns raised 4 Failure to alleviate service users’ distress and improve engagement during repeated crisis contacts View source Failure to provide an evident handover from the crisis team to the community psychiatric nurse View source Insufficient crisis team resources to meet service demand View source Failure to provide continuity of crisis team care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Implement the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Recruit a full-time psychologist to provide psychological-intervention support, supervision and staff support within the Crisis team.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Monitor compliance with the revised Crisis-to-CMHT discharge process through the designated Crisis Service responsibility.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019. View source
Action
Develop a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source See 7 more actions
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AI-generated summary
Kim Morris · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kim Morris died from the consequences of suspension by ligature after being found in the garage at home and resuscitated. The report raises concerns about a lack of continuity within the crisis team, inadequate handover to community psychiatric nursing, and whether the service was suitable to support high-risk individuals. It states that these pressures and service concerns remained unresolved.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to alleviate service users’ distress and improve engagement during repeated crisis contacts
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member , or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an evident handover from the crisis team to the community psychiatric nurse
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment . She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient crisis team resources to meet service demand
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available . The service remains on the Trust’s “at risk” register .
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care . This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuity of crisis team care
Wider context from the report “Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals , and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris . It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.
The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.
There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.
My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
Verbatim wording from the response “Service response
The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Town for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
Verbatim wording from the response “Service response
We accept our continuity of care is challenged and want to assure you we are committed to improve this area of care with the new investment outlined above. We have already implemented new ways of allocating registered clinicians for assessments to increase the time available to deliver treatment. Registered staff members are now rostered four weeks of carrying out assessments only. Outside of these blocks they will then focus on treatment. This process was implemented in” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
Verbatim wording from the response “Service response
The additional investment will support our commitment to improving the continuity of care of all patients in Crisis we support. This includes the review of our local guidance for staff on pre-visit preparation, which expects all staff to read the previous visit entry, review any recent risk assessments, confirm outstanding actions from the previous visit have been completed, and check any communication needs prior to the scheduled visit. We will develop a spot check tool to establish that the changes as the result of the review of the local guidance have been imbedded into practice. We will ensure that we are able to offer assurances of our compliance on this through co-producing a spot check tool directly with our service users.” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
Verbatim wording from the response “2. It was accepted that Mrs Morris be referred to a Community Psychiatric Nurse to continue her engagement and continuity of care prior to discharge, but no contact was made prior to her discharge, potentially leaving her fearful of a delay.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
Verbatim wording from the response “1. There were numerous visits and telephone encounters with many different individuals and the role of the key worker did not reduce these.” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
Verbatim wording from the response “June 2019 and the team are currently monitoring the impact this has on continuity of care.
In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Recruit a full-time psychologist to provide psychological-intervention support, supervision and staff support within the Crisis team.
Verbatim wording from the response “equivalent unregistered staff. These additional staff will increase the capacity of the team, and alleviate some of the known high demand and pressures. A full time Psychologist is also being recruited to support psychological interventions and will provide supervision and support to staff in the team. We are expecting that this additional support will be fully in place by the end February 2020.” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Monitor compliance with the revised Crisis-to-CMHT discharge process through the designated Crisis Service responsibility.
Verbatim wording from the response “Service response
The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Town for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.” Source location 2019-0261-Response-by-Leicestershire-Partnership-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 Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
Verbatim wording from the response “Service Response
We acknowledge your concerns that we are not able to offer a service to support such high risk individuals, and would like to reassure you that, as a Trust we take these concerns seriously. We have received additional investment to further enhance the Crisis Service, to enable us to improve the service we deliver.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
Verbatim wording from the response “June 2019 and the team are currently monitoring the impact this has on continuity of care.
In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.” Source location 2019-0261-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 4 Failure to routinely involve carers and families in the care of mentally unwell patients View source Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries View source Lack of remote access to medical records for on-call psychiatry clinicians View source Failure to monitor the outcomes of amended induction processes 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
John Charles Hazlewood · 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
John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely involve carers and families in the care of mentally unwell patients
Wider context from the report “2. Mr Hazlewood’s partner was repeatedly expressed to be his main or only protective factor from self-harm. She was not approached for information regarding his overdose, or her concerns regarding his escalating behavior and this missed an opportunity for the fuller picture to be captured when considering care planning and mental health assessment. This is an issue that I have raised with the Leicester Partnership Trust before in the matter of ████████ and it appears that carers/families are still not being routinely involved in the care of mentally unwell patients . This can create intolerable pressures upon families and leads to poor outcomes such as in these 2 cases. LPT are urged to consider how this matter can be embedded in training and practice.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries
Wider context from the report “4. University Hospitals of Leicester staff, both Dr and nurse gave evidence to the Court that they had not received any training in self harm , notwithstanding they were both highly likely to encounter patients attending with self-inflicted injuries regularly in both the Emergency Department and in the Acute Medical Admissions unit. With self-harm statistics sad soaring, this is an increasing matter of concern. It is not appropriate to rely on “buying in” psychiatric services and leaving front line staff treating patients with no basic knowledge of this complex area and potential triggers . Training would empower the staff and is likely to assist them both in caring for the patients but also the carers/families who may need advice and support. NICE guidelines CG16 is clear that training should be provided to all staff who may encounter such patients and UHL should therefore reconsider this matter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of remote access to medical records for on-call psychiatry clinicians
Wider context from the report “1. The court heard that the on call Dr for psychiatry did not have remote access to Mr Hazlewood’s medical records and this prevented her from being informed of his significant psychiatric history , and furthermore prevented her from writing a note of her discussions regarding his request to self-discharge. Therefore the knowledge that he had presented again via ED with a serious overdose was not available to his Consultant so an opportunity was missed to escalate his care. Many of the on call team do have remote access and the Leicester Partnership Trust are asked to consider this issue for all relevant clinicians in order to avoid future difficulties of communication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor the outcomes of amended induction processes
Wider context from the report “3. The court was assured that the induction process had been changed to improve knowledge regarding on call procedures and availability of medical record access. No information was available, via audit, of whether this amended process is successful . LPT should ensure that the outcomes of their welcome changes are being effectively monitored to ensure clinicians have appropriate training and understanding given the frequent rotations of staff and the importance of the on call system being robust and reliable.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide relevant psychiatry trainees and specialist trainees with remote access to all required clinical record systems.
Verbatim wording from the response “████████, Clinical Director, has confirmed that all trainees on the relevant rota in Adult Mental Health and Learning Disabilities service now have remote access to the same clinical systems they would be able to access if they were working on the Trust’s sites. This means that all” Source location 2018-0189-Response-by-Leicestershire-Partnershire-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 Distribute a Whole Family Approach Bulletin to staff every two months to share family and carer involvement learning and good practice.
Verbatim wording from the response “We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.” Source location 2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand family and carer content in record-keeping audits and monitor compliance through weekly audits and monthly clinical governance.
Verbatim wording from the response “We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.” Source location 2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete supervision sessions for Mental Health Triage staff focused on family and carer involvement in assessment and improved working practice.
Verbatim wording from the response “Staff in our Assessment and Triage Team endeavor to elicit carers’ and families’ views regarding the care and treatment of patients, this enables us to gain an understanding of the whole person. However, this is clearly not always as effective as we would like. Although we implemented a number of actions in 2015 in response to the death of Mr. Abel, it is clear we need to continue to reinforce the importance of effective communication with families/carers. With this in mind, our senior Matron will complete work with the teams to ensure all staff in our Mental Health Triage team have a supervision session with the focus on family and carer involvement in the assessment process and discuss ways in which they can improve this within their working practice. This will be completed by October 2018.” Source location 2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Mental Health Triage and Crisis staff with NICE guidance on family and carer involvement.
Verbatim wording from the response “We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda.” Source location 2018-0189-Response-by-Leicestershire-Partnershire-NHS-Trust
Open published response
Concerns raised 5 Unclear incident reporting entry and amendment systems View source Inadequate and inaccurate communication with families of patients with mental health issues View source Ineffective diary systems for referrals to different specialisms View source Delays in immediate post-fall attendance, examination and basic observations View source Delays in senior review of reported incidents View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margery Annie Astill · 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
Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations were completed.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear incident reporting entry and amendment systems
Wider context from the report “(1) Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and inaccurate communication with families of patients with mental health issues
Wider context from the report “(2) Communication with family members was inadequate and inaccurate , the “named nurse” system was ineffective and therefore opportunities were lost to share information and to keep the family informed and involved. The failure of the Trust to engage with family members of patients with mental health issues have been raised in the past as a concern , and contrary to NICE Guidelines.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective diary systems for referrals to different specialisms
Wider context from the report “(1) Diary systems for ensuring referrals to different specialisms were not effective , such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in immediate post-fall attendance, examination and basic observations
Wider context from the report “(3) Mrs Astill had two unwitnessed falls during her time in the unit, both were recorded on CCTV and both were due to interaction with other patients. The first fall was quickly attended by numerous nursing staff members, but there was a considerable delay in actually physically attending to the patient, examining her or taking basic observations . In a professional nursing environment this delay in first aid provision was of concern and the Trust should consider enhanced training to ensure immediate effective interventions
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in senior review of reported incidents
Wider context from the report “(1) Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion.
” 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 clinical emergency drills with immediate reflection and feedback for participating staff.
Verbatim wording from the response “In addition to the above, I can confirm that the Trust Resuscitation Committee is overseeing the implementation of clinical drills. These drills re-enact patient emergency situations in the clinical setting in which staff on duty will participate in and will then be offered immediate practice reflection and feedback with regard to how they have responded to and managed this in practice.” Source location 2017-0440-Leicestershire-Partnership-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 Implement a ward-diary procedure defining task allocation and documentation, with ongoing monthly audits.
Verbatim wording from the response “Mental Health Services Older Persons (MHSOP) Ward Staff Teams have developed, and are in the process of implementing, a Standard Operating Procedure for the safe and effective management of the ward diary. Implementation is being led and embedded in daily practice by the Senior Inpatient Matrons and undertaken by each individual Ward Matron. The process also clearly defines how the ward tasks will be allocated and documented. This process will be subject to an ongoing monthly audit to provide assurance that this is being embedded in practice.” Source location 2017-0440-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke communication-skills training to nurses involved in the incidents.
Verbatim wording from the response “The Trust acknowledges that the communication shared with the family following both the incidents was not an accurate description of the events which was later revealed in the CCTV footage. When the staff involved in the incidents provided Mrs Astill’s family with information regarding her falls, their form of communication did not convey the accuracy of the situation. In order to enhance the nursing staff with their communication skills, the nurses involved have subsequently attended a bespoke training course delivered by LOROS (Leicester Hospice Charity). This training course supports enhanced communication skills needed to support patients and relatives.” Source location 2017-0440-Leicestershire-Partnership-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 Display posters on each ward defining the named nurse’s role for patients and carers.
Verbatim wording from the response “The service has approved the updated named nurse role and responsibility patient and carer information leaflet. Posters will be displayed on each ward defining the role of the named nurse to ensure that both patients and carers are clear about what to expect. A named nurse checklist has also been established to support Registered Nurses to carry out this role. This provides a clear accountability and audit trail whilst setting standards around timely communication with relatives and carers.” Source location 2017-0440-Leicestershire-Partnership-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 Review CCTV footage to determine whether Basic Life Support and Immediate Life Support training requires organisational or individual changes.
Verbatim wording from the response “The Trust resuscitation lead has the responsibility for the Resuscitation Councils (UK) Basic Life Support and Immediate Life Support training. As part of their review they will analyse the CCTV footage to understand if there are any organisational changes required to the training, or if this is purely an individual training requirement.” Source location 2017-0440-Leicestershire-Partnership-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 Establish the updated named-nurse information leaflet and checklist supporting accountability and timely communication with relatives and carers.
Verbatim wording from the response “The service has approved the updated named nurse role and responsibility patient and carer information leaflet. Posters will be displayed on each ward defining the role of the named nurse to ensure that both patients and carers are clear about what to expect. A named nurse checklist has also been established to support Registered Nurses to carry out this role. This provides a clear accountability and audit trail whilst setting standards around timely communication with relatives and carers.” Source location 2017-0440-Leicestershire-Partnership-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 Schedule further experiential learning and practice-development training on person-centred responses to emergency medical situations.
Verbatim wording from the response “The MHSOP Clinical Education Lead is also scheduling in further experiential learning and practice development training opportunities to reflect on the immediate person centred approach to support emergency medical situations.” Source location 2017-0440-Leicestershire-Partnership-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 Undertake a spot-check audit against NICE quality standards for hospital care involving older-person mental-health inpatient admissions.
Verbatim wording from the response “The Trust further acknowledges the Coroner’s concern that it has not engaged with family members of patients with mental health issues which is contrary to Nice Guideline 136¹. With particular reference to mental health services for older people and inpatient admissions the service will be undertaking a spot check audit against the quality standard’s as set out for hospital care.” Source location 2017-0440-Leicestershire-Partnership-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 Operate daily incident analysis supported by the Patient Safety Team.
Verbatim wording from the response “MHSOP currently formally review all incidents weekly however there is a system in place for daily incident analysis which is supported by the Trust’s Patient Safety Team that assures that the correct processes are being followed.” Source location 2017-0440-Leicestershire-Partnership-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 Daily incident analysis, supported by the Patient Safety Team, is considered sufficient to assure that correct incident-review processes are followed.
Verbatim wording from the response “MHSOP currently formally review all incidents weekly however there is a system in place for daily incident analysis which is supported by the Trust’s Patient Safety Team that assures that the correct processes are being followed.” Source location 2017-0440-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 7 Failure to identify the roles and responsibilities of involved health and social care professionals View source Lack of a local community support network for patients diagnosed with personality disorder View source Failure to review patients after 2 admissions within 6 months View source Lack of local psychiatric intensive care unit beds for female patients View source Lack of effective community psychiatric nurse involvement View source Failure to adhere to the care programme approach View source Unavailability of community support for patients with challenging presentations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Victoria Georgia Halliday · 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
Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the roles and responsibilities of involved health and social care professionals
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a local community support network for patients diagnosed with personality disorder
Wider context from the report “5) There is no local network for the community support of patients diagnosed with personality disorder , although evidence suggested such networks were effective when adopted elsewhere.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients after 2 admissions within 6 months
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months , and to ensure the roles and responsibilities of all health and social care professionals involved were identified.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local psychiatric intensive care unit beds for female patients
Wider context from the report “1) There are currently no local psychiatric intensive care unit beds for female patients and this means all female patients can only be placed out of area, potentially many miles away from home and local 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective community psychiatric nurse involvement
Wider context from the report “2) There was no, or no effective, community psychiatric nurse involvement and this was a missed opportunity to monitor and assist Victoria when she was in the community.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the care programme approach
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of community support for patients with challenging presentations
Wider context from the report “3) The “community support” referred to by the in-patient clinicians does not exist in reality for patients with this challenging presentation , leaving discharged patients and their families without adequate support.
” 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 Continue negotiating commissioner contracts for provision of the proposed personality-disorder services.
Verbatim wording from the response “Further to our response to concern 3, LPT is not commissioned to provide an “enhanced service” to provide support and treatment for people with a severe and complex personality disorder (SCPD) in the community. A group of our senior clinical and operational leaders, with support from Commissioners, are working together to develop an integrated clinical pathway and model for care for people with Personality Disorders. As part of this proposal a dedicated team to provide this enhanced service is proposed, the purpose of which is to provide an intensive community based treatment support for both patients in treatment, and in crisis. The aim is to link the pathway together with supporting services in primary care, social care, and Police. We continue to work with our commissioners to negotiate our 2017/2018 contracts for provision of services, of which this remains an ambition to provide.” Source location Response from Leicestershire Partnership 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 integrated clinical pathway and care model for people with personality disorders, including a proposed bespoke enhanced community service.
Verbatim wording from the response “However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.” Source location Response from Leicestershire Partnership 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 Ensure team staff understand the process for allocating a community worker after assessment, including through new-starter induction.
Verbatim wording from the response “In this case, the lack of effective CPN input during the time Victoria was a community patient was an isolated incident, with the assessing CPN failing to follow the standard operating team process, whereby the assessing worker accepts the person onto their case load if they have capacity. If they don’t have capacity the assessing worker should present the outcome of the assessment at the next Multi-Disciplinary team (MDT) meeting in order to allocate to a Community Worker/CPN within the Team.” Source location Response from Leicestershire Partnership 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 a Standard Operating Procedure clarifying CPA roles, care-coordinator allocation, transfers, community allocation and required reviews.
Verbatim wording from the response “In order to ensure roles and responsibilities of health and social care professionals involved in the CPA process are clear, understood and adhered to, a Standard Operating Procedure (SOP) is under development. Included in this SOP it will confirm and clarify the process to identify a Care Co-ordinator for patients in in-patient services, and will confirm and clarify the transfer and allocation process for the identification of the Care Co-ordinator in the community team, and associated reviews required.” Source location Response from Leicestershire Partnership 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 Complete a formal twice-yearly CPA audit across adult mental health inpatient and community services and develop resulting action plans.
Verbatim wording from the response “A formal bi-annual CPA audit across AMH in-patient and community services has recently been completed and action plans developed. There are specific questions within the audit in relation to the CPA Care Plan, showing a clear description of needs and there being a description of the action to be taken and by whom. The audit completed in 2014 showed good compliance in these areas.” Source location Response from Leicestershire Partnership 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 Direct provision of local female psychiatric intensive care beds is outside the Trust’s commissioning remit.
Verbatim wording from the response “Service Response
LPT is not currently commissioned to directly provide Female Psychiatric Intensive care beds (PICU). Our commissioners are in the process of procuring a local, medium to long term solution, for female Psychiatric Intensive Care Unit (PICU) placements in Leicester, Leicestershire and Rutland. The procurement process is unlikely to be resolved until 2017/18. For patients who are placed out of area, through our Adult Mental Health (AMH) Bed Management Team, we keep in touch on a weekly basis with the placement providers to ensure that length of stay out of area is for an agreed period of time, and that repatriation back to local services is facilitated at the earliest opportunity. In Victoria’s case, referrals to PICU were made from the Bradgate inpatient area due to her challenging presentation and its impact on staff.” Source location Response from Leicestershire Partnership 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 Providing an enhanced community service for people with severe and complex personality disorder is outside the Trust’s current commissioning remit.
Verbatim wording from the response “However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.” Source location Response from Leicestershire Partnership 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 Commissioners are responsible for developing and commissioning the proposed enhanced severe and complex personality disorder community service.
Verbatim wording from the response “However the community support as mentioned by the inpatient consultants refers to an “enhanced service” for people with severe and complex personality disorder (SCPD) who are difficult to maintain in the community with existing standards services and they inadvertently access acute services (inpatient and crisis services). LPT is currently not commissioned to provide this “enhanced service”. Some Trusts have adopted innovative practice which is commissioned to address this gap and LPT is doing the same with our Commissioners in proposing testing a bespoke service for people with SCPD as part of a wider Personality Disorder service development.” Source location Response from Leicestershire Partnership NHS Trust
Open published response
×
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 Commissioners are responsible for procuring a local medium- to long-term solution for female psychiatric intensive care placements.
Verbatim wording from the response “Service Response
LPT is not currently commissioned to directly provide Female Psychiatric Intensive care beds (PICU). Our commissioners are in the process of procuring a local, medium to long term solution, for female Psychiatric Intensive Care Unit (PICU) placements in Leicester, Leicestershire and Rutland. The procurement process is unlikely to be resolved until 2017/18. For patients who are placed out of area, through our Adult Mental Health (AMH) Bed Management Team, we keep in touch on a weekly basis with the placement providers to ensure that length of stay out of area is for an agreed period of time, and that repatriation back to local services is facilitated at the earliest opportunity. In Victoria’s case, referrals to PICU were made from the Bradgate inpatient area due to her challenging presentation and its impact on staff.” Source location Response from Leicestershire Partnership NHS Trust
Open published response
×
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 lack of effective community psychiatric nurse input was an isolated incident, not evidence that community support generally did not exist.
Verbatim wording from the response “A standard community service exists within LPT for people with personality disorder in the form of community mental health team (CMHT), Crisis Resolution Team (CRT) and Specialist Personality Disorder Service (FDL). Victoria was accessing all these services during the course of her contact with LPT. An identified Community Psychiatric Nurse (CPN) from the CMHT, CRT was present during professional and CPA meetings whilst Victoria was an inpatient. Due to the nature of Victoria’s presentation of presenting in different areas of the country in a crisis covering CPNs and CRT professionals tried to ensure continuity as much as possible.” Source location Response from Leicestershire Partnership NHS Trust
Open published response
Concerns raised 4 Lack of support for high-risk patients and their main carers after discharge View source Failure to maintain documentary proof of discharge notification calls View source Failure to provide immediate written discharge and high-risk notification to the crisis team View source Severe anxiety and deepening depression associated with living at home View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Anthony John Preston · 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
Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of support for high-risk patients and their main carers after discharge
Wider context from the report “(4) As a result, Mr Preston and his main carer ████████ were left without support at a time when he was at high risk .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain documentary proof of discharge notification calls
Wider context from the report “(2) The system for discharge of patients, whereby a nurse makes contact with (in this case) the Leicestershire Crisis Team does not appear to have been robust . There was no documentary proof of the telephone call .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide immediate written discharge and high-risk notification to the crisis team
Wider context from the report “(3) There was no immediate follow up by email or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Severe anxiety and deepening depression associated with living at home
Wider context from the report “(1) Mr Preston had demonstrated, in his early return from home leave in the first few days of November, that living at home was a source of substantial stress, and likely to cause him severe anxiety and deepen his depression .
” Open source report
Concerns raised 6 Failure to provide robust, effective and event-responsive complex case planning View source Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes View source Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records View source Failure to formalise multidisciplinary team meetings View source Failure to investigate suspected overdose events and apply learning outcomes View source Under-utilisation of enhanced case management for complex prisoners View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ahmedreza Fathi · 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
Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide robust, effective and event-responsive complex case planning
Wider context from the report “1. Healthcare complex case planning was not robust or effective , and was not reviewed or updated in response to subsequent events . Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions . Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise multidisciplinary team meetings
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate suspected overdose events and apply learning outcomes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes . This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Under-utilisation of enhanced case management for complex prisoners
Wider context from the report “2. The enhanced case management system referred to in PSI 64/11 was under-utilised for a prisoner of this complexity and further consideration should be given to its role in situations of this nature.
” Open source report
Concerns raised 5 Unavailability of call bell systems in patient bedrooms View source Failure to complete fluid balance charts consistently and accurately View source Failure of nursing staff to recognise signs and symptoms of physical illness View source Failure to conduct Level 2 observations at prescribed intervals View source Failure to carry out Level 2 observations in accordance with protocol View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Granville Oswald Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Granville Oswald Hughes was a patient at the Bradgate Unit who was found unresponsive on his bedroom floor at approximately 02:00 on 23 April 2014. The report identified concerns about failures in 15-minute observations, incomplete fluid balance charts, the lack of bedroom call bells, and nursing staff’s understanding of physical illness signs and symptoms.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of call bell systems in patient bedrooms
Wider context from the report “3. Patient bedrooms are not fitted with a call bell system. The staff rely on patients being able to leave their bedroom and seek help or be able to shout loudly enough to be heard. Clearly, a patient who is so unwell that they can do neither would not be able to alert staff that assistance was required.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fluid balance charts consistently and accurately
Wider context from the report “2. Fluid balance charts were not properly completed. There was no uniformity as to how or when staff would record fluid intake. Some staff would record fluid if they gave Mr. Hughes a drink. Some would record if they witnessed Mr Hughes drink it. Therefore, the fluid balance charts were rendered meaningless.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to recognise signs and symptoms of physical illness
Wider context from the report “4. The nursing staff who gave evidence were Registered Mental Health Nurses or Health Care Support Workers. The evidence that they gave suggested they may not appreciate the signs and symptoms of a physical problem / illness. One nurse said that he would not. Although it is understood that discussions have taken place regarding the recruitment of 5 Registered General Nurses to supplement the 2 already in post at the Bradgate Unit and address this concern, it is understood that recruitment has not yet occurred and no date for commencement of recruitment could be given.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct Level 2 observations at prescribed intervals
Wider context from the report “1. Level 2 observations were not conducted at the prescribed time intervals and periods of up to two hours lapsed between observations that should have been conducted every 15 minutes. When observations were conducted they were not always carried out as per the protocol. Assurances have been given at previous inquests that the performing and recording of these observations would be monitored, audited and staff would be trained regarding the importance of such observations. The same assurances were given at Mr. Hughes' inquest. It therefore appears that changes have not been made or if they have they are not working. Alternatively, changes may occur in the short-term but they are not being maintained and therefore the monitoring and auditing systems, if implemented, appear not to be working.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out Level 2 observations in accordance with protocol
Wider context from the report “1. Level 2 observations were not conducted at the prescribed time intervals and periods of up to two hours lapsed between observations that should have been conducted every 15 minutes. When observations were conducted they were not always carried out as per the protocol. Assurances have been given at previous inquests that the performing and recording of these observations would be monitored, audited and staff would be trained regarding the importance of such observations. The same assurances were given at Mr. Hughes' inquest. It therefore appears that changes have not been made or if they have they are not working. Alternatively, changes may occur in the short-term but they are not being maintained and therefore the monitoring and auditing systems, if implemented, appear not to be working.
” 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 Present preferred call-bell options to the Service Finance and Performance Committee for an investment decision.
Verbatim wording from the response “The service will conduct an appraisal and feasibility study to facilitate appropriate (individual patient) call-bell facilities by 31 July 2016. The preferred options will be presented to the Service Finance and Performance Committee by September 2016 for investment decision.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report missed observations through the incident system, review them by the ward matron, and interview responsible staff with action taken where necessary.
Verbatim wording from the response “All missed observations should be reported through the incident reporting system and are subsequently reviewed by the relevant ward matron. Responsible clinical staff involved in late or missed observations are interviewed and action taken where necessary.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the reviewed fluid-balance documentation approach and support it with training for all clinical staff.
Verbatim wording from the response “The lead Dietician for Adult Mental Health has been asked to review the fluid chart and its relationship to the Trust Hospital Nutrition and Hydration Policy. It is expected the review of the forms will be completed by the end of April 2016 and implementation will be supported by training to all clinical staff.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Therapeutic Observation Policy to determine how physical-health observations should be incorporated or separately guided.
Verbatim wording from the response “The Therapeutic Observation Policy will be reviewed by 30 April 2016 to consider how the completion of therapeutic observation for physical health concerns should be included or if separate guidance is required.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an appraisal and feasibility study for appropriate individual-patient call-bell facilities.
Verbatim wording from the response “The service will conduct an appraisal and feasibility study to facilitate appropriate (individual patient) call-bell facilities by 31 July 2016. The preferred options will be presented to the Service Finance and Performance Committee by September 2016 for investment decision.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the fluid balance chart and its relationship to the Trust Nutrition and Hydration Policy.
Verbatim wording from the response “The lead Dietician for Adult Mental Health has been asked to review the fluid chart and its relationship to the Trust Hospital Nutrition and Hydration Policy. It is expected the review of the forms will be completed by the end of April 2016 and implementation will be supported by training to all clinical staff.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a review of appropriate call-bell options for Mental Health areas.
Verbatim wording from the response “There are currently 6 rooms identified for patients with physical disabilities in that have call bells in Mental Health Acute Inpatient Services. Traditional call bell systems are not appropriate for Mental Health areas (due to the ligature risks they present), which means the Trust does not have call bells fitted to all Mental Health bedroom areas. However, the service is currently completing a review of appropriate options.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the Bradgate general nurse team through a further recruitment cycle for new posts.
Verbatim wording from the response “Although mental health nurses do have training in basic physical healthcare the service acknowledges the benefits to patients of integrating additional General Nurses into each ward's multi-disciplinary team and it is the service's commitment to facilitate this.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Therapeutic Observation Policy with competency-based training and competency checks before staff lead patient observations.
Verbatim wording from the response “The poor practice demonstrated by staff regarding observations at the time of the incident is unacceptable and is not tolerated. A new version of the Trust's Therapeutic Observation Policy was implemented in 2015 with staff competency based training in the practical application of the policy. The policy is aimed at observing patients in relation to risk of harm, however does include assessment of physical wellbeing. All staff who carry out therapeutic observations are competency checked by a ward nurse or matron before they are allowed to lead on a patient's observations. This is applicable for all ward substantive and bank staff.” Source location David-Hughes-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise admission of patients with physical disabilities or illness to disabled or call-bell-equipped bedrooms.
Verbatim wording from the response “During the interim period, increased observations levels will be set for those patients who present as physically unwell. The frequency of these observations will be agreed within the multi-disciplinary team and adjusted as required by clinical assessment. Bradgate Unit patients presenting with physical disabilities or illness will be prioritised admission into our disabled or call-bell equipped bedrooms.” Source location David-Hughes-Response
Open published response
×
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 Traditional call-bell systems cannot be fitted throughout mental health bedroom areas because of the ligature risks they present.
Verbatim wording from the response “There are currently 6 rooms identified for patients with physical disabilities in that have call bells in Mental Health Acute Inpatient Services. Traditional call bell systems are not appropriate for Mental Health areas (due to the ligature risks they present), which means the Trust does not have call bells fitted to all Mental Health bedroom areas. However, the service is currently completing a review of appropriate options.” Source location David-Hughes-Response
Open published response
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.
×
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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Leicestershire Partnership NHS Trust; 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 Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.
Verbatim wording from the response “The LPT Discharge Policy is currently under review and the new policy is due to be approved in February 2016.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require relevant information for patients and families to be documented in assessments and care plans.
Verbatim wording from the response “The CMHTs have also been informed in writing that relevant information must be made available for patients and their families, where this is provided it must be documented and made part of each individual’s assessment and care planning.” Source location 2015-0443-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require medical and nursing staff to notify GPs when patients miss outpatient appointments.
Verbatim wording from the response “We agree with the inquest findings that communication between the Community Mental Health Team (CMHT) and wider stakeholders was poor. We agree that LPT did fail to communicate the fact that Barry did not attend his outpatient appointment to his GP and the steps regarding open contacts taken to prevent this happening in the future have been detailed are outlined above.” Source location 2015-0443-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publicize and distribute the developed Trust Carers’ Pack to provide carers with information about processes and services.
Verbatim wording from the response “assist service improvement. The first event in the programme is to be held in January 2016. Additionally a Trust Carers’ Pack has been developed as part of an established CQUIN (Commissioning for Quality and Innovation) to provide information to carers about processes and services. The availability of the same will be widely publicized by the ward, outpatient staff, and service user and carer organisations. Team managers will be asked to cascade to all staff once it is completed and ready for distribution. It is anticipated that this will be completed by March 2016.” Source location 2015-0443-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind community mental health staff to follow the Did Not Attend policy for missed appointments.
Verbatim wording from the response “Actions taken/planned:” Source location 2015-0443-Response2
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 Conduct regular spot checks of compliance with the Did Not Attend policy.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
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 new patients and recent non-attenders with appointment reminders, and alert clinicians to missed appointments for risk assessment.
Verbatim wording from the response “Specifically our new patients are now being contacted a week before their scheduled appointment to remind them of the appointment date and time. If a patient is unable to attend then the appointment can be offered to someone else. Patients who missed their last appointment are also telephoned to remind them to attend and these patients are also bought to the attention of the clinician so that an assessment can be made as to whether or not any further action is required. A text reminder facility is available to patients who opt into the service and the publicity for this is being reviewed to encourage take up.” Source location 2015-0443-Response2
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 Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
Verbatim wording from the response “Since the beginning of November 2015 what are known as ‘open contacts’ on the patient electronic record (RiO) are being monitored on a weekly basis. This is where a patient has had an appointment date that has passed but the episode of care has not been closed on the record, either by a record of the appointment having taken place or evidence of a further appointment offered. These will be drawn to the” Source location 2015-0443-Response2
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 Did Not Attend policy during quarter two of 2016/17.
Verbatim wording from the response “We have informed our entire medical and nursing staff, in writing dated 1 December 2015 that they MUST write to GPs informing them about patients who Do Not Attend at our outpatient clinics as stated in the LPT DNA policy. In addition we will carry out an audit of the DNA policy to check compliance against the standards in the policy during quarter 2 of 2016/17. The record keeping audit, being scheduled for January 2016 will also include the recording of compliance with the standards within the revised discharge policy as described under point 2.” Source location 2015-0443-Response2
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 Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
Verbatim wording from the response “In the period between completion of the investigation and leading up to the Coroner’s inquest LPT has been undertaking a programme of specific work to ensure that the maximum use of clinical appointment slots are available in the Adult Mental Health Outpatients department thereby increasing the availability of appointments to our patients. This will reduce the numbers of people who are not attending appointments.” Source location 2015-0443-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate an interim missed-appointment flow chart to community mental health teams.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Did Not Attend policy and introduce a flow chart for responding to missed appointments.
Verbatim wording from the response “All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of being reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following a missed appointment while awaiting the release of the new policy. The flow chart is attached as appendix 2.” Source location 2015-0443-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.
Verbatim wording from the response “Actions taken/planned:” Source location 2015-0443-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a partial-booking system for outpatient appointments.
Verbatim wording from the response “LPT is also working towards a ‘partial booking’ system for outpatient appointments whereby appointments are booked much closer to the scheduled date to be seen allowing for a more flexible use of available appointments and a reduction in cancelled clinics. Cancelling of clinics is sometimes unavoidable but it is subject to Clinical Director approval and an action plan to monitor compliance and improvement is scrutinized for assurance at the LPT Quality Assurance Committee.” Source location 2015-0443-Response2
Open published response
Concerns raised 4 Failure to discuss family involvement and provide information about the mental health problem and its treatments View source Failure to obtain relevant family information before taking no further action View source Inadequate communication of professional concerns and safe-keeping expectations to family members View source Failure to conduct a Mental Health Assessment after a person expressing suicidal intention was safely escorted from railway lines View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Abel · 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
William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss family involvement and provide information about the mental health problem and its treatments
Wider context from the report “3. NICE guidelines (Clinical guidance 136) state that health care professionals should discuss whether the patient would like the family to be involved in their care, and to provide them with information to understand the mental health problem and its treatments. This guideline does not appear to have been met in this case.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant family information before taking no further action
Wider context from the report “2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of professional concerns and safe-keeping expectations to family members
Wider context from the report “2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family , as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping . No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a Mental Health Assessment after a person expressing suicidal intention was safely escorted from railway lines
Wider context from the report “1. Mr Abel had a diagnosis of paranoid schizophrenia and he was still under the care of the Mental Health services at the time he was found in the vicinity of the railway lines, expressing suicidal intention. He had missed appointments and there was a history of non-compliance with medication. Staff were available to have conducted a Mental Health Assessment, on the night he was safely escorted from the railway lines, but this was not done.
” 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 Introduce an assessment-outcome and plan form providing patients and, with consent, accompanying carers or family members written advice and access information.
Verbatim wording from the response “The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it. This will also be given to a carer, friend or family member if they are present at the assessment and the patient has consented to their involvement. We will implement this change for the Triage Car team by the end of December 2015 and the wider Crisis Team by the end of January 2015.” Source location 2015-0406-Response-by-Leicester-Partnership-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 Remind Triage Car and Crisis Team staff about the family-involvement protocol and patient choice through managers and team meetings.
Verbatim wording from the response “The Triage Car and Crisis Team have both been reminded of this protocol via their team manager and their team meetings during November 2015.” Source location 2015-0406-Response-by-Leicester-Partnership-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 Revise the Triage Car Mental Health Act assessment protocol to require consideration and documentation of decisions and reasons.
Verbatim wording from the response “The protocol for Mental Health Practitioners working with the Triage Car is being revised so that where there are clear indicators which prompt a discussion with a patient about the possibility of an admission to an Acute Hospital and a patient refuses to consider an informal admission, a Mental Health Act Assessment will be considered. If the assessment is not undertaken, the reasons for this decision taken within the context of the patient’s presentation and the conferences of the contact with the services, will be clearly documented. The changes to the protocol have been communicated via email to the Triage Car and Crisis Team via the service and team managers and the final revised protocol will be discussed in both team meetings. The communication exercise was completed during November 2015.” Source location 2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the revised Mental Health Act assessment protocol and report findings and further actions.
Verbatim wording from the response “We will undertake an audit to monitor compliance of the revised protocol in December 2015 and report the audit and further actions to be taken in January 2016.” Source location 2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document family members’ presence, offer them opportunities to provide views and observations, and include this information in assessment outcomes.
Verbatim wording from the response “Family members’ presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment.” Source location 2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Open published response
Concerns raised 2 Failure to recognise abnormal observations and escalate care View source Failure to provide healthcare staff with relevant clinical information before observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derick James Stanmore · 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
Derick James Stanmore, who was serving a life sentence in HMP Gartree and had recognised medical conditions including heart disease and type II diabetes, complained of chest pains on 7 July 2014. He collapsed in his cell on 10 July 2014 and was pronounced deceased shortly after arriving at hospital; the inquest recorded acute myocardial infarction due to coronary artery atheroma. Concerns included abnormal observations not being recognised or acted upon and the attending nurse not accessing available healthcare records before taking observations.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise abnormal observations and escalate care
Wider context from the report “1. Observations were taken on the morning of Mr. Stanmore’s death by a registered nurse. The observations were abnormal and required further action to be taken but this was not recognised. A system similar to the hospital “Early Warning Score” (EWS) may assist the healthcare staff in recognising this and escalating care accordingly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide healthcare staff with relevant clinical information before observations
Wider context from the report “2. The nurse attending Mr. Stanmore did not access his healthcare records that were available and did not appear to have any information regarding the need for a healthcare assessment . He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context . Consideration should be given to ensuring all staff have appropriate access whenever possible to information before conducting examinations or observations of prisoners.
” 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 Introduce an adapted Track and Trigger system across three prison healthcare teams and train staff to use it.
Verbatim wording from the response “The Healthcare Management / Clinical Leadership Team will be introducing an adapted version of the Track and Trigger system as attached. Staff will need to be trained in the use of this tool across our three Prison Healthcare Teams and we anticipate that this will be in place by the 1 October 2015.” Source location 2015-0172-Response-by-Leicestershire-Partnership-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 Remind staff to access clinical notes during routine prisoner consultations to inform clinical decisions.
Verbatim wording from the response “After review, I can confirm that all staff are able to access clinical information prior to seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order to make a well informed clinical decision.” Source location 2015-0172-Response-by-Leicestershire-Partnership-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 Provide all staff with access to clinical information before seeing prisoners.
Verbatim wording from the response “After review, I can confirm that all staff are able to access clinical information prior to seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order to make a well informed clinical decision.” Source location 2015-0172-Response-by-Leicestershire-Partnership-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 Clinical information is already accessible to all staff before prisoners are seen, addressing the need for appropriate access.
Verbatim wording from the response “After review, I can confirm that all staff are able to access clinical information prior to seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order to make a well informed clinical decision.” Source location 2015-0172-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 4 Insufficiently robust and timely capture of available healthcare information View source Over-reliance on prisoners’ accounts instead of previous recorded risk factors View source Over-reliance on others to make further enquiries about statements of depression and self-harm View source Failure to consistently open ACCTs for prisoners presenting with self-harm or other risks View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Greg Revell · 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
Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust and timely capture of available healthcare information
Wider context from the report “7. The system for capturing all available healthcare information was insufficiently robust. There was no clear monitoring of obtaining a GP summary promptly to ensure medications and previous medical history could be checked as soon as possible. An opportunity for restarting anti-depressant medication in this case was missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on prisoners’ accounts instead of previous recorded risk factors
Wider context from the report “4. There was over reliance upon what the Prison Officers were told by Greg, and insufficient emphasis on previous recorded risk factors in documentation available to them.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on others to make further enquiries about statements of depression and self-harm
Wider context from the report “5. There was a culture of over-reliance on “others” being responsible for enquiring further into statements regarding depression and self harm made by Greg, rather than any focus on individual responsibility.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently open ACCTs for prisoners presenting with self-harm or other risks
Wider context from the report “1. Greg had been a prisoner at Glen Parva YOI earlier the same year, and on that occasion presented with a florid and undiagnosable ligature mark on his neck from an attempt at self harm shortly before his imprisonment. Notwithstanding this, he was not placed on an ACCT.
2. There was confusion amongst Prison Officers who gave evidence regarding when it was appropriate to open an ACCT.
3. There was suggestion that there would be “too many ACCTS” and they would be ineffective if all prisoners with risks were placed on an ACCT.
” 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 a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.
Verbatim wording from the response “We now have a robust system in regard how clinical information is sought and there is a flow chart (Attachment 1) identifying team member's responsibilities to ensure consistency and follow up if required. This flowchart details the responsibility of each discipline within the team to ensure that there is a robust mechanism in place to ensure that Prisoners Clinical Notes are requested and followed up.” Source location 2015-0165-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 6 Conflict between policies governing hospital-community transfer arrangements and equipment provision and ordering View source Insufficient training of discharge staff on the intended and appropriate use of bed rails View source Inappropriate discharge care planning View source Inadequate co-ordination between services View source Non-implementation of the alert system for communication between all stakeholders View source Failure to follow up or assess hospital-ordered equipment in the community View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry Denis Whitwell Powell · 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
Henry Denis Whitwell Powell, who had advanced dementia and required 24-hour care, died on 11 August 2014 after a fall while climbing over bed rails, suffering a head injury and not regaining consciousness. The principal concerns were inappropriate discharge care planning, misunderstanding and insufficient training regarding bed rails, and inadequate coordination and follow-up between hospital and community services for equipment provision.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Conflict between policies governing hospital-community transfer arrangements and equipment provision and ordering
Wider context from the report “(2) There is a conflict currently between the policies governing transfer arrangements between hospital (UHL) and community (LPT) and the provision and ordering of equipment , which can now be done directly by 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of discharge staff on the intended and appropriate use of bed rails
Wider context from the report “(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate discharge care planning
Wider context from the report “(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate co-ordination between services
Wider context from the report “(3) Co-ordination between services is inadequate , resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Non-implementation of the alert system for communication between all stakeholders
Wider context from the report “(4) Equipment is supplied by a single gatekeeper, NRS Healthcare, and an alert system is intended to ensure communication has taken place between all stakeholders, but I was advised this system has not been implemented ; early implementation would assist in resolving the current difficulties.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up or assess hospital-ordered equipment in the community
Wider context from the report “(3) Co-ordination between services is inadequate, resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community .
” 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 a shared Safe Use of Bedrails policy defining roles, responsibilities and training requirements across LPT, UHL and ICES.
Verbatim wording from the response “Our Lead Nurse for Community Services, Community Health Service division is leading the development of a shared policy for the safe use of bedrails. Representatives from LPT, UHL, ICES and West Leicestershire Clinical Commissioning Group have met and agreed the areas for development and wider consideration. The draft combined policy will be available for each organisation to adopt by the end of April 2015.” Source location 2015-0058-Response-by-Leicestershire-Partnership-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 Continue rolling out falls training for healthcare professionals.
Verbatim wording from the response “Our health care professionals working within an in-patient setting are trained in the appropriate use of bed rails through the essential to role falls training. All staff working within these areas have undertaken a clinical workbook that incorporates falls training. The clinical workbook is being replaced with a continuous roll out training programme for all healthcare professionals. Currently compliance records for falls training is held locally on each ward. We are in the process of establishing how training compliance can be reported on divisionally to enable wider scrutiny.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and agree a universal bedrail risk-assessment tool, standardised care plans and consistent transfer-of-care arrangements.
Verbatim wording from the response “Our Lead Nurse for Community Services, Community Health Service division is leading the development of a shared policy for the safe use of bedrails. Representatives from LPT, UHL, ICES and West Leicestershire Clinical Commissioning Group have met and agreed the areas for development and wider consideration. The draft combined policy will be available for each organisation to adopt by the end of April 2015.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide minimum bedrail information and define staff responsibilities for continuing risk assessment during patient transfers and discharge.
Verbatim wording from the response “The newly devised shared policy for the safe use of bedrails will include the responsibilities of staff when transferring patients, stating when and who will provide on-going risk assessments. For patients discharged from healthcare services with an on-going need for bed rail use with formal or informal carers a minimum standard of information will be provided. The local authorities have been involved to determine the most appropriate transfer of care arrangements for those patients who do not have a continued health care need.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require confirmation of completed bedrail assessment and risk assessment before permitting bedrail orders through the NRS Healthcare system.
Verbatim wording from the response “An alert on the NRS Healthcare ordering system has been put in place.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring relevant staff training up to date for bedrail use, including falls and mandatory moving-and-handling training.
Verbatim wording from the response “Our health care professionals working within an in-patient setting are trained in the appropriate use of bed rails through the essential to role falls training. All staff working within these areas have undertaken a clinical workbook that incorporates falls training. The clinical workbook is being replaced with a continuous roll out training programme for all healthcare professionals. Currently compliance records for falls training is held locally on each ward. We are in the process of establishing how training compliance can be reported on divisionally to enable wider scrutiny.” Source location 2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 4 Lack of maintained and audited analysis of failed visits and untoward outcomes View source Failure of clinicians to respond robustly to failed home visits View source Lack of specific time targets for escalation action View source Failure to maintain an appropriate threshold for requesting welfare checks View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Laura Page · 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
Laura Page experienced social stresses, sought medical support, and later took overdoses requiring psychiatric care. She died on 4 December 2012 after taking a substantial overdose. Concerns included failed community-team home visits, inadequate escalation and welfare-check thresholds, incomplete discharge arrangements, and poor inter-agency communication.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of maintained and audited analysis of failed visits and untoward outcomes
Wider context from the report “Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning.
(1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate.
(2) The escalation policy should be reviewed to consider specific time targets for action.
(3) The threshold for requesting a welfare check should be reconsidered.
(4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinicians to respond robustly to failed home visits
Wider context from the report “Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning.
(1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate.
(2) The escalation policy should be reviewed to consider specific time targets for action.
(3) The threshold for requesting a welfare check should be reconsidered.
(4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific time targets for escalation action
Wider context from the report “Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning.
(1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate.
(2) The escalation policy should be reviewed to consider specific time targets for action.
(3) The threshold for requesting a welfare check should be reconsidered.
(4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared.
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an appropriate threshold for requesting welfare checks
Wider context from the report “Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning.
(1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate.
(2) The escalation policy should be reviewed to consider specific time targets for action.
(3) The threshold for requesting a welfare check should be reconsidered.
(4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared.
” 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 Reconsider and clarify the threshold for requesting welfare checks in the failed-visit flowchart.
Verbatim wording from the response “(3) The threshold for requesting a welfare check should be reconsidered.” Source location 2014-0254-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 Reinforce staff expectations to engage patients, follow the operational procedure when engagement fails, and communicate failures during handovers.
Verbatim wording from the response “We are aware that the difficulty in this case was essentially one of communication. We have endeavoured to make it clear to staff that they must do all that they can to engage with a patient. Where they are unable to do so, this must be dealt with in accordance with the Operational Procedure. This will enhance communication within the team so that a failure to engage will be seen by the relevant team. This will assist in the handover meetings.” Source location 2014-0254-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 Conduct weekly audits of failed visits and monitor compliance through key performance indicators.
Verbatim wording from the response “The Crisis Service Manager is now undertaking a weekly audit check on failed visits to assure compliance in line with the new process, and is monitored through key line performance indicators.” Source location 2014-0254-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify crisis teams of the Regulation 28 outcome and disseminate the standardized failed-visit process through meetings, email, flowcharts, and updated procedures.
Verbatim wording from the response “The teams within the Crisis Service were notified of the outcome and the contents of the Regulation 28 at their team meetings and via email communication.” Source location 2014-0254-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider obtaining access through police-held key fobs for appropriate failed-visit situations.
Verbatim wording from the response “In terms of the issue of key fobs, this is not a practical resolution to the problem of a failure to engage with the patient. However, the Police do have access to such fobs and consideration has been given to this in terms of obtaining access.” Source location 2014-0254-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 Review escalation arrangements and establish specific time targets for action in the failed-visit flowchart.
Verbatim wording from the response “(2) The escalation policy should be reviewed to consider specific time targets for action.” Source location 2014-0254-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 a standardized failed-visit process requiring qualified-practitioner visits where possible and escalation when staffing cannot be secured.
Verbatim wording from the response “A clear process has also been developed and put in place to ensure that all failed visits are dealt with following the same process. This is detailed in the attached flow chart (Annex).” Source location 2014-0254-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 Key fobs are not considered a practical resolution to failed patient engagement; police access is available and obtaining access has been considered.
Verbatim wording from the response “In terms of the issue of key fobs, this is not a practical resolution to the problem of a failure to engage with the patient. However, the Police do have access to such fobs and consideration has been given to this in terms of obtaining access.” Source location 2014-0254-Response
Open published response
Concerns raised 2 Failure to exchange prescription information between treatment services and the GP View source Failure to maintain regular contact between treatment services and the GP 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
Michael Anthony Tarratt · 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
Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to exchange prescription information between treatment services and the GP
Wider context from the report “(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services , to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain regular contact between treatment services and the GP
Wider context from the report “(1) Despite Evidence from the Drug and Alcohol team that it was appropriate to update the relevant GP every 3 months, or at least every 6 months, it was accepted on this occasion that no contact had been made for 18 months . Consideration should be given to more regular contact between the services providing treatment .
” 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 Audit case notes for GP correspondence within 14 days and repeat the audit every six months.
Verbatim wording from the response “A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter.” Source location 2014-0115-Response-by-Leicestershire-Partnership-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 Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.
Verbatim wording from the response “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.” Source location 2014-0115-Response-by-Leicestershire-Partnership-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 Notify Drug and Alcohol team staff of required GP communication after assessment, at least every three months, when treatment changes or risks arise, and at discharge.
Verbatim wording from the response “A notification by way of urgent memo by email has been sent to all members of the Drug & Alcohol team that the agreed standard for communication and correspondence with patients’ GPs is that contact must be made with the GP:” Source location 2014-0115-Response-by-Leicestershire-Partnership-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 Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.
Verbatim wording from the response “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.” Source location 2014-0115-Response-by-Leicestershire-Partnership-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 Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.
Verbatim wording from the response “The Leicester Recovery Partnership’s working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state:” Source location 2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Open published response
Concerns raised 5 Failure to share known bleeding information with other health care professionals View source Lack of training and/or experience for appropriate clinical practice View source Lack of professional insight into the potential fatal consequences of clinical actions View source Failure to seek medical advice before administering anticoagulants despite known bleeding View source Lack of insight into the risk of continued unsafe practice causing future deaths View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Re-inform CHS healthcare professionals about medicines-management standards, communication responsibilities, relevant case learning, and the community medicines SOP through email cascades, briefings, meetings, and SOP reissue.
Stated plannedThe respondent said that this action was planned when they made their response on 5 September 2013. View source
Action
Provide medicines-management and emotional-resilience training, monthly clinical supervision for six months, and reflective-practice assessment to strengthen the nurse’s clinical decision-making.
Stated plannedThe respondent said that this action was planned when they made their response on 5 September 2013. View source
Action
Continue implementing mobile working so community nursing and therapy staff can access patient records in patients’ homes and communicate with linked GP practices.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2013. View source
Action
Commission a review and improvement of communication processes operating within the Single Point of Access.
Stated plannedThe respondent said that this action was planned when they made their response on 5 September 2013. View source See 1 more action
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AI-generated summary
Labuben Amarsi Vaghadia · 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
Mrs Vaghadia developed bleeding after receiving an anticoagulant injection for suspected deep vein thrombosis and died in hospital on 27 August 2012 from haemorrhage and haematoma of the abdominal wall. Concerns included the community nurse administering a further anticoagulant injection without seeking medical advice despite knowing about the bleeding, failing to share that information with other healthcare professionals, and lacking training, experience, and insight into the potential risks of her actions.
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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share known bleeding information with other health care professionals
Wider context from the report “(2) Although the nurse had full knowledge of the bleeding she did not share this with other health care professionals when she spoke to them . If she had there was a real possibility that Mrs Vaghadia would have been admitted sooner. In this instance, the expert opined that on a balance of probabilities had Mrs Vaghadia been admitted sooner the outcome was unlikely to have been different. Nevertheless, full and appropriate information sharing is paramount and the nurse’s actions fell short of her professional duties and could have caused an adverse outcome .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training and/or experience for appropriate clinical practice
Wider context from the report “(4) Although not causing or contributing to Mrs Vaghadia’s death, it is clear that Nurse ████████ actions were not appropriate. I have a concern that Nurse ████████ lacks training and/or experience as well as insight that her actions and therefore her practice may continue and cause future deaths
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional insight into the potential fatal consequences of clinical actions
Wider context from the report “(3) Nurse ████████ appeared to have no professional insight into her actions and that they could cause or contribute to death .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical advice before administering anticoagulants despite known bleeding
Wider context from the report “(1) Community Nurse ████████ administered the anticoagulant on the 26th August 2012 without seeking medical advice from a Doctor even though she knew Mrs Vaghadia had been bleeding from the site of the previous injection . Although the expert evidence in this case is that the nurse’s actions did not cause or contribute to the death in this instance, there is a risk that such action in another case may not have the same outcome and could be causative of death .
” 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 Leicestershire Partnership NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of insight into the risk of continued unsafe practice causing future deaths
Wider context from the report “(4) Although not causing or contributing to Mrs Vaghadia’s death, it is clear that Nurse ████████ actions were not appropriate. I have a concern that Nurse ████████ lacks training and/or experience as well as insight that her actions and therefore her practice may continue and cause future deaths
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-inform CHS healthcare professionals about medicines-management standards, communication responsibilities, relevant case learning, and the community medicines SOP through email cascades, briefings, meetings, and SOP reissue.
Verbatim wording from the response “It is accepted fully that part of a health professional's responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professional responsibility regarding this issue via a system of email cascade. Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health.” Source location 2013-0201-Response-by-Leicestershire-Partnership-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide medicines-management and emotional-resilience training, monthly clinical supervision for six months, and reflective-practice assessment to strengthen the nurse’s clinical decision-making.
Verbatim wording from the response “As a result of this process Nurse ████████ is judged to be competent in all areas of clinical practice assessed. However in response to the concerns raised a programme of training has now been arranged for Nurse ████████ which includes medicines management training and emotional resilience training. In addition she will participate in additional clinical supervision on a monthly basis for six months and undertake a reflective practice assessment, the sum of which is to strengthen her clinical decision making skills.” Source location 2013-0201-Response-by-Leicestershire-Partnership-NHS
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 Continue implementing mobile working so community nursing and therapy staff can access patient records in patients’ homes and communicate with linked GP practices.
Verbatim wording from the response “For further assurance I advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients' notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA.” Source location 2013-0201-Response-by-Leicestershire-Partnership-NHS
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 Commission a review and improvement of communication processes operating within the Single Point of Access.
Verbatim wording from the response “For further assurance I advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients' notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA.” Source location 2013-0201-Response-by-Leicestershire-Partnership-NHS
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 nurse was judged competent in all assessed areas of clinical practice, disputing concerns about inadequate competence, training and experience.
Verbatim wording from the response “As a result of this process Nurse ████████ is judged to be competent in all areas of clinical practice assessed. However in response to the concerns raised a programme of training has now been arranged for Nurse ████████ which includes medicines management training and emotional resilience training. In addition she will participate in additional clinical supervision on a monthly basis for six months and undertake a reflective practice assessment, the sum of which is to strengthen her clinical decision making skills.” Source location 2013-0201-Response-by-Leicestershire-Partnership-NHS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations