LPFT Legal Services

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First report 12 Oct 2022•Latest report 26 Oct 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from LPFT Legal Services linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Lincolnshire

    AI-generated summary

    Vincenzo Joseph Michael LIPPOLIS · 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

    Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.

    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 LPFT Legal Services; that does not assign responsibility.

    PFD Monitor interpretation

    Premature closure of the mental health assessment case

    Wider context from the report

    “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”
    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 LPFT Legal Services; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake face-to-face assessment after recent suicide attempts

    Wider context from the report

    “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”
    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 LPFT Legal Services; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider Mental Health Act admission criteria

    Wider context from the report

    “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”
    Open source report

  2. Lincolnshire

    AI-generated summary

    Emma Jane SIMKIN · 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

    Emma Jane SIMKIN, also known as Emilie Zukiard AFFIN, died on 20 February 2021 after standing in front of a freight train at Railway Lineside, Spitalgate Hill, Grantham, and receiving non-survivable injuries. The report raises concern that people may mask mental illness in front of professionals, who may accept what they are told without sufficiently considering evidence from families, and asks whether policies and training addressing this issue are adequate.

    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 LPFT Legal Services; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider primary evidence from families alongside patients’ accounts when assessing masked mental illness

    Wider context from the report

    “Families are repeatedly advising their perception is that loved ones are successfully "masking" their mental illnesses in front of professionals who are perceived to accept at face value what they are told rather than looking at other primary evidence more often than not from the families themselves. which in turn leads the families to believe they are being ignored and lives lost. Can you reassure me that policies are in place that focus upon how to identify "masking" and adequate training to the appropriate professionals is up to date and consider if policies are in need of review. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026