2 Nov 2018 Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report Manchester West
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Concerns raised 9 Sub-optimal Mental Health Act assessment performance View source Failure to complete Mental Health Act assessment forms in the required format with the required practitioner information View source Failure to implement a revised Multi Disciplinary Team agenda approach View source Failure to record interim deterioration advice and action information View source Failure to formulate risk clearly and undertake collaborative safety planning View source Failure to obtain collateral histories during Mental Health Act assessments View source Failure to revise and implement the Community Mental Health Team operational procedure View source Failure of mental health liaison practitioners to maintain records, follow systems and protocols, and involve practitioners in decision making View source Failure of operational procedures to ensure nurses' concerns are taken into account in specialist evaluation and detention decisions View source See 6 more concerns
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Karl Qolf Jamil Englemak Cassimjee · 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
Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.
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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal Mental Health Act assessment performance
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal ;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Mental Health Act assessment forms in the required format with the required practitioner information
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner ;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a revised Multi Disciplinary Team agenda approach
Wider context from the report “2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:
a. The need for the Community Mental Health Team operational procedure to be revised;
b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases ;
c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process;
However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned ;
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure to record interim deterioration advice and action information
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim ).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate risk clearly and undertake collaborative safety planning
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain collateral histories during Mental Health Act assessments
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure to revise and implement the Community Mental Health Team operational procedure
Wider context from the report “2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:
a. The need for the Community Mental Health Team operational procedure to be revised ;
b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases;
c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process;
However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned ;
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health liaison practitioners to maintain records, follow systems and protocols, and involve practitioners in decision making
Wider context from the report “2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:
a. The need for the Community Mental Health Team operational procedure to be revised;
b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases;
c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process ;
However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned ;
” 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 Manchester Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation Failure of operational procedures to ensure nurses' concerns are taken into account in specialist evaluation and detention decisions
Wider context from the report “1. Brief circumstances of matter of concern
a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);
b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;
c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;
d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.
e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).
f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar , to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.
” 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