26 Aug 2020 Toby Peter Edward Nieland · Prevention of Future Deaths report Lincolnshire
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Concerns raised 14 Lack of assertive outreach and organised welfare checks after community discharge View source Failure to seek immediate family views on accommodation and treatment and care pathways View source Failure to communicate immediate family concerns to relevant care agencies View source Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis View source Lack of an adequate Care Programme Approach View source Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures View source Unavailability of specialist Dual Diagnosis workers for complex cases View source Unavailability of a dedicated or commissioned drug and alcohol recovery service View source Lack of interface between senior or experienced providers for complex cases View source Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis View source Failure to recognise and adequately manage complex Dual Diagnosis View source Failure to appoint a care coordinator to monitor care under an appropriate care plan View source Lack of coordination between mental health and addiction services View source Absence of a Dual Diagnosis protocol defining provider roles View source See 11 more concerns
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Toby Peter Edward Nieland · 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
Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assertive outreach and organised welfare checks after community discharge
Wider context from the report “6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies ) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek immediate family views on accommodation and treatment and care pathways
Wider context from the report “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate immediate family concerns to relevant care agencies
Wider context from the report “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased , nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training , in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an adequate Care Programme Approach
Wider context from the report “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures
Wider context from the report “5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a series of acceptable relapse signatures ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist Dual Diagnosis workers for complex cases
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases ;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a dedicated or commissioned drug and alcohol recovery service
Wider context from the report “7. The circumstances of this case evidences a gap in the provision of care to a patient with a Dual Diagnosis in Lincolnshire by reason of there being no dedicated and/or commissioned drug and alcohol recovery team/service ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of interface between senior or experienced providers for complex cases
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases ;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
Wider context from the report “8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and adequately manage complex Dual Diagnosis
Wider context from the report “2. Unequivocal evidence established that the deceased suffered from an advanced progressive addiction overlaid with a vulnerable personality amounting to a complex Dual Diagnosis – the significance of which was not appreciated and therefore not managed adequately or appropriately ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a care coordinator to monitor care under an appropriate care plan
Wider context from the report “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of coordination between mental health and addiction services
Wider context from the report “3. In any event, even on the basis upon which community care was deemed appropriate, there was an absence of any co-ordination between mental health service provision and addiction services ;
” 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 Lincolnshire Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a Dual Diagnosis protocol defining provider roles
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time ) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce that clinicians may receive information from families and carers without patient consent to share information.
Verbatim wording from the response “In cases where explicit consent has not been given by a patient to share their sensitive personal information; the Trust has taken action to remind clinicians that information from families and carers can still be received. The Carers Lead for the Trust continues to work with the Divisional Leads; Learning and Development and also the Communications Team to reinforce the message to staff that they can still receive information from Carers and Families even when consent is not given from the patient to share information. In Mr Nieland’s case it was unfortunate the Trust were not made aware of any concerns held by the family, however there is the clear commitment to learn from this and to consider what needs to be in place to strengthen communication and to actively encourage feedback.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging commissioners and system partners to secure appropriate funding for dual-diagnosis services and support.
Verbatim wording from the response “vi. To continue to engage with Commissioners and all system partners including primary care, acute care services, and housing partners (not named in the letter but we recognise the importance of all partners in the system) to ensure the services required for patient with dual diagnosis are appropriately funded – clinical, management and leadership and administrative support. Lead: Director of Strategy, Planning and Partnerships - on-going” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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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 revised suicide-prevention training covering history, accommodation, relationships and substance and alcohol misuse risk factors.
Verbatim wording from the response “Learning from the tragic death of Mr Nieland, the Trust has taken steps to enhance the training offered to staff about assessing risk of suicide to reinforce the complex interplay of factors mentioned above including previous history, accommodation and employment needs, substance and alcohol misuse patterns and relationships. This revised suicide prevention training will be rolled out to all staff commensurate with their role and clinical responsibility, within the next 6-12 months.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.
Verbatim wording from the response “Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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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 robust communication, information-sharing and aligned clinical pathways with We Are With You.
Verbatim wording from the response “The Trust and ‘We Are With You’ (as Addaction is now called) will work together to ensure the implementation of robust communication systems; agree appropriate information sharing arrangements and ensure alignment of clinical pathways and protocols, with the aim to make collaborative working between the two organisations standard practice. The Trust confirms this is part of its work plan over the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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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 family and carer involvement in care, including receiving carer information and sharing information with patient consent.
Verbatim wording from the response “iv. To reinforce and further embed the important role of carers and family members in providing the right quality care to patients and to support carers in getting involved with their loved ones’ care, including receiving information from carers and sharing information with consent from patients. Lead: Service Manager for Carers and Peer Support – Ongoing” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.
Verbatim wording from the response “We have summarised below the actions the Trust will take to learn from Mr Nieland’s death and enhance services for patients with a complex dual diagnosis presentation: To review internal policies and protocols as well as work together with “We Are With You” to embed care pathways between the two organisations to address gaps in services. (Leads: Clinical Director for Community Division and Quality Lead for the Community Division)” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify commissioning gaps and deploy appropriately skilled dual-diagnosis workers across partner agencies.
Verbatim wording from the response “Learning from the death of Mr Nieland, as stated above, the Trust is committed to the strengthening of its policies and protocols in accordance with the guidance issued by NICE and the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care Programme Approach which will have joint working with We Are With You’, utilising expertise of workers from both services in a collaborative manner. The Trust has already begun conversations with its Commissioning partners and We Are With You, to identify commissioning gaps and ways of ensuring workers with the right skills are deployed in both agencies.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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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 Care Programme Approach to ensure appropriate care-coordinator allocation, including for all patients with dual diagnosis.
Verbatim wording from the response “v. To review the Care Programme Approach to ensure the right decisions are made about allocating care coordinators to patients and also to ensure that all patients with a dual diagnosis are allocated a care coordinator. Lead: The Trust Quality and Safety Lead – by 31 April 2021.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review training and competencies to cover dual-diagnosis presentations, risk assessment and information sharing.
Verbatim wording from the response “The Trust is committed to a review of the training provided to staff to ensure they are appropriately equipped with the knowledge and ability to care for patients with dual diagnosis. The Learning and Development Lead is working with Divisional staff to develop the appropriate training package, over the next 6-12 months.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A police welfare check was not considered necessary based on the information available at the time.
Verbatim wording from the response “The Trust was informed by the out of area inpatient unit that Mr Nieland had been discharged into the community. In accordance with Trust policy and national guidance, the Trust’s Crisis Resolution and Home Treatment Team offered timely follow-up appointments with Mr Nieland to assess his risk and care arrangements. Based upon the information available at the time, a clinical decision to request a police welfare check was not considered necessary. The Trust appreciate the importance of the views of family and carers has in formulating appropriate care arrangements for patients. With the benefit of hindsight, it is accepted that the knowledge and concerns of Mr Nieland’s family would have better informed assessment of risk. The Trust is continuing to support staff and to emphasise the importance of working and supporting patients to include family and carers in their care.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust was not commissioned to provide substance misuse services.
Verbatim wording from the response “The Trust recognises there is currently a commissioning gap in the provision of care to patients identified as having a dual diagnosis. Currently mental health services and substance misuse services are commissioned separately in Lincolnshire with the services provided by two organisations. The Trust is a provider of specialist mental health services and is not commissioned to provide substance misuse services. The local Clinical Commissioning Groups (CCG) and the Local Authority’s Public Health department commission ‘We Are With You’ (formerly ‘Addaction’) to provide substance misuse services.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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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 Commissioning Groups and the Local Authority’s Public Health department commissioned substance misuse services from the external provider.
Verbatim wording from the response “The Trust recognises there is currently a commissioning gap in the provision of care to patients identified as having a dual diagnosis. Currently mental health services and substance misuse services are commissioned separately in Lincolnshire with the services provided by two organisations. The Trust is a provider of specialist mental health services and is not commissioned to provide substance misuse services. The local Clinical Commissioning Groups (CCG) and the Local Authority’s Public Health department commission ‘We Are With You’ (formerly ‘Addaction’) to provide substance misuse services.” Source location 2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations