10 Mar 2026 Surendrakumar Patel · Prevention of Future Deaths report Worcestershire
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Concerns raised 8 Failure to consider and advocate for family contact View source Delays in full medical assessment by a senior healthcare professional View source Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids View source Lack of prison staff awareness of the HMP Hewell food refusal policy View source Lack of healthcare staff awareness of the food refusal policy View source Failure to recognise when mental capacity assessment is required after food refusal begins View source Failure to ask the prisoner whether food refusal information should be shared View source Failure to consider hospital transfer for prisoners severely weakened by weight loss View source See 5 more concerns
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AI-generated summary
Surendrakumar Patel · 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
Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and advocate for family contact
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in full medical assessment by a senior healthcare professional
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff awareness of the HMP Hewell food refusal policy
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy , including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare staff awareness of the food refusal policy
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy :
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when mental capacity assessment is required after food refusal begins
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask the prisoner whether food refusal information should be shared
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider hospital transfer for prisoners severely weakened by weight loss
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be 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 Ensure partner healthcare policies affecting mental health services are shared in advance for clinical input and alignment.
Verbatim wording from the response “MPFT recognises that where policies held by partner organisations have implications for mental health services, there must be clear engagement to ensure shared understanding and effective implementation across providers.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 Disseminate relevant policies within mental health teams with guidance on roles, responsibilities, and interfaces with primary care.
Verbatim wording from the response “2. Targeted Dissemination and Awareness
MPFT will ensure that relevant policies impacting mental health practice are clearly disseminated within its teams, with explicit guidance on roles, responsibilities, and expected interfaces with primary care services.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 Active clinical observation through ACCT and food refusal processes was sufficient before psychiatric assessment.
Verbatim wording from the response “It is also relevant that the period between the reported onset of food refusal (21 October 2024) and multidisciplinary review (24 October 2024) was brief, and during this time Mr Patel remained under active clinical observation, including management through ACCT and food refusal processes.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 PPG, not MPFT, holds responsibility for physical healthcare, food refusal policy implementation, and initial capacity assessment.
Verbatim wording from the response “MPFT provides integrated mental health and psychosocial substance use services within HMP Hewell. Primary responsibility for physical healthcare, including nutritional monitoring, implementation of food refusal policies, and initial assessment of capacity in the context of food refusal, sits with the primary healthcare provider, Practice Plus Group (PPG).” Source location Response from Midlands Partnership NHS Foundation Trust
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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 clinical presentation did not indicate a need for more urgent psychiatric assessment.
Verbatim wording from the response “At the time of assessment, his presentation was not indicative of a clear acute mental illness requiring urgent psychiatric intervention. In addition, records indicate that from 24 October onwards he was taking fluids and intermittently consuming food.” Source location Response from Midlands Partnership NHS Foundation Trust
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Concerns raised 1 Lack of guidance on steps to take when high serum clozapine levels are returned View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Turner · 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
Mr Turner was a 63-year-old man who was found deceased at his home on 18 April 2025; a postmortem identified citalopram toxicity as the cause of death. The concern raised was that there was no local or national guidance on what steps to take when a high serum level is returned in patients monitored while taking clozapine.
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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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on steps to take when high serum clozapine levels are returned
Wider context from the report “1. That when a high serum level is returned in patients being monitored as they are taking clozapine, there is no guidance, locally or nationally as to what steps should be taken .
” 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 Maintain a clozapine standard operating procedure covering prescribing, monitoring, administration, supply and assessment of serum levels.
Verbatim wording from the response “Midlands Partnership University Hospitals Trust does have a Standard Operating Procedure (SOP) in place relating to clozapine. We are sorry that the evidence heard at inquest contradicted the actual position. The SOP sets out the criteria which need to be adhered to when using clozapine to ensure safe and effective practice and includes information and support to clinicians in relation to the prescribing, monitoring, administration and supply of clozapine. The current version of the SOP has been in place since July 2024 and was in place at the time of Mr Turner’s death in April 2025. A copy of the SOP is attached for ease.” Source location 2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
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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 Recirculate the clozapine standard operating procedure to all Integrated Mental Health Team prescribers in Burntwood and Lichfield.
Verbatim wording from the response “The SOP is readily available for all staff to access on the Trust’s intranet site. Since the inquest the SOP has been recirculated to all prescribers in the Integrated Mental Health Team in Burntwood and Lichfield. The application of this SOP has also been discussed with the team.” Source location 2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
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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 Guidance cannot be more prescriptive because individual toxicity, clinical response and mental-health risks require clinician-specific decisions.
Verbatim wording from the response “The SOP contains what is considered to be guidance to support clinical decision making. There are a number of patient variability factors that would need to be taken into account when clinical staff are making decisions, for example, the clinician would need to consider if the patient is displaying any signs of toxicity and if there would be any potential impact on the patient’s mental health if clozapine were to be reduced or stopped, ahead of making a decision and for that reason guidance is not more prescriptive.” Source location 2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
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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 Trust SOP already provides local guidance on assessing high clozapine serum levels.
Verbatim wording from the response “That when a high serum level is returned in patients being monitored as they are taking clozapine, there is no guidance, locally or nationally as to what steps should be taken.” Source location 2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
Open published response
Concerns raised 3 Lack of access to other teams’ electronic notes during suicide risk assessments View source Failure to conduct risk assessments properly View source Failure to address staff training needs 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
Mr William Anthony Grieve · 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
Mr William Anthony Grieve was found deceased at his home on 20 August 2024. The inquest recorded hanging as the cause of death and concluded with suicide. Concerns included separate electronic systems preventing Stoke Talking Therapies and the Stoke crisis Evolution Team from accessing each other’s notes, resulting in incorrect suicide risk assessments, and staff training needs not being addressed.
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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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to other teams’ electronic notes during suicide risk assessments
Wider context from the report “2. Both assessments, were incorrect, and took account of incorrect information because neither had access to the others computer system . Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo. There was no way for either team to see the others electronic notes .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct risk assessments properly
Wider context from the report “3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this. The concern being that staff training needs are not being addressed.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address staff training needs
Wider context from the report “3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this . The concern being that staff training needs are not being addressed .
” 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 new process for assessing and documenting patient risk without risk stratification.
Verbatim wording from the response “As a service, Staffordshire and Stoke on Trent Talking Therapies introduced a new process of assessing and documenting risk which came into force on 1 May 2025.” Source location Response from Midlands Partnership University NHS Foundation Trust
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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 Train all Talking Therapies staff on the new risk-assessment and documentation processes and provide a supporting resource pack.
Verbatim wording from the response “All staff working in the service received training on the new processes in April 2025. The training comprised of a live training session which was recorded for staff who were absent to watch at their earliest opportunity. A resource pack was also provided to all staff outlining in writing the new processes and requirements for assessing risk and writing this in notes.” Source location Response from Midlands Partnership University NHS Foundation Trust
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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 Conduct monthly audits from July 2025 to check compliance with the new risk processes and identify further training needs.
Verbatim wording from the response “Following implementation, a robust auditing process will be taking place monthly from July 2025 to ensure compliance and address any further staff training needs.” Source location Response from Midlands Partnership University NHS Foundation Trust
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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 Urgent or serious risks should be escalated immediately to secondary care under existing national Talking Therapies guidance rather than through shared record access.
Verbatim wording from the response “6. Nationally, it is not usual practice that secondary care staff have access to the Talking Therapies record system for the clinical and cost reasons outlined above. If urgent or serious risk presents in Talking Therapies services, it is standard and expected practice that these risks should be escalated to secondary care within the system immediately as per Talking Therapies national guidance, due to there being no medical staff in the team to advise on this.” Source location Response from Midlands Partnership University NHS Foundation Trust
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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 NSCHT is responsible for providing and overseeing Talking Therapies in Stoke, including mandatory training for the locality team.
Verbatim wording from the response “MPFT holds the contract for Talking Therapies in Staffordshire and Stoke on Trent, and sub-contracts to other partners. There are 7 different organisations who sub-contract from MPFT, NSCHT are one such provider. NSCHT provide the Talking Therapies services in Stoke, who I understand provided treatment to Mr Grieve.” Source location Response from Midlands Partnership University NHS Foundation Trust
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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 Widening IAPTUS access is not currently considered feasible because of confidentiality, consent, supervision-note, system and data-protection constraints.
Verbatim wording from the response “1. Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS staff for therapy. They have been consented that their notes will remain confidential from other NHS services unless there are issues of risk or safeguarding, to assure them that their colleagues will not be able to view those psychological therapy notes. To open this access to IAPTUS and other NHS Staff poses a risks of breaches of confidentiality and a risk that staff will no longer come forward to access the service.” Source location Response from Midlands Partnership University NHS Foundation Trust
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11 Oct 2024 Oliver Davies · Prevention of Future Deaths report Worcestershire
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Concerns raised 4 Failure to incorporate self-harm risk referrals into mental-health care prioritisation View source Failure to escalate anticipated inability to provide mental-health care before leave View source Failure to highlight recent mental-health and self-harm risk information in medical records for clinical assessment View source Delays in initial mental-health care coordinator appointments due to workload pressures 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
Oliver Davies · 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
Oliver Davies died by suicide by hanging in his cell at HMP Hewell on 31 December 2022. The concerns included delayed and incomplete mental health assessment, failures to share relevant information about his self-harm and suicide risk, inadequate prioritisation and follow-up by the mental health care coordinator, and failures to keep him informed about healthcare and appointments.
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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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate self-harm risk referrals into mental-health care prioritisation
Wider context from the report “2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 16-28.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating ( green ). When conducting that RAG rating exercise, the care coordinator did not take into account:
(a) The prison officer’s urgent TAG mental health referral of 30.11.22 ( above ); and
(b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record.
In addition, the care coordinator did not raise in the mental health team’s daily forum.the fact that he was unlikely to have time to see Oliver before he went on leave.
Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead.
Having heard evidence at the inquest from your Trust’s Clinical Director, ████████, I was not satisfied that the Trust has fully recognised the above shortcomings, and taken action to ensure that they are not repeated for other mental health patients in custody at HMP Hewell.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate anticipated inability to provide mental-health care before leave
Wider context from the report “2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 16-28.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating ( green ). When conducting that RAG rating exercise, the care coordinator did not take into account:
(a) The prison officer’s urgent TAG mental health referral of 30.11.22 ( above ); and
(b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record.
In addition, the care coordinator did not raise in the mental health team’s daily forum.the fact that he was unlikely to have time to see Oliver before he went on leave.
Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead.
Having heard evidence at the inquest from your Trust’s Clinical Director, ████████, I was not satisfied that the Trust has fully recognised the above shortcomings, and taken action to ensure that they are not repeated for other mental health patients in custody at HMP Hewell.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight recent mental-health and self-harm risk information in medical records for clinical assessment
Wider context from the report “1) Oliver had been at HMP Hewell since 20.10.22. He was a man with long-standing mental health issues, for whom this was a first experience of custody. After a steady deterioration in his mental state, a mental health referral on 17.11.22 led to a belated mental health examination conducted by a registered learning disability nurse on 6.12.22. In the week leading up to the nurse’s assessment:
(a) A prison officer had made an urgent TAG mental health referral on 30.11.22, citing concerns that Oliver was experiencing active thoughts of self-harm or suicide, and that he (the officer) had “mild concerns” about intentional self-harm, and there were “definite indicators” of unintentional self-harm; and
(b) Oliver himself had submitted a healthcare application form asking to see a doctor, saying that he was “extremely depressed”, his anxiety was “really high” and he was “not coping at all, please help”;
These important events were not highlighted on Oliver’s SystmOne medical record , and so the nurse conducting the assessment 6.12.22 was not aware of either of these important recent events, and did not take them into account when assessing Oliver ;
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in initial mental-health care coordinator appointments due to workload pressures
Wider context from the report “2) Oliver was allocated a care coordinator on 6.12.12 following the nurse’s assessment. An appointment was fixed for Oliver to meet the care coordinator for the first time on 14.12.22. Due to workload pressures, the care coordinator was unable to fulfil that appointment before he went on leave from 16-28.12.22. Shortly before he went on leave, the care coordinator conducted a “RAG rating” exercise to determine whether he should prioritise seeing Oliver, and determined that Oliver’s case merited the lowest priority RAG rating ( green ). When conducting that RAG rating exercise, the care coordinator did not take into account:
(a) The prison officer’s urgent TAG mental health referral of 30.11.22 ( above ); and
(b) A further TAG mental health referral made by a prison paramedic which cited “mild concerns” about deliberate and unintentional self-harm on Oliver’s part, the details of which had been entered onto Oliver’s SystmOne medical record.
In addition, the care coordinator did not raise in the mental health team’s daily forum.the fact that he was unlikely to have time to see Oliver before he went on leave.
Had the care coordinator taken into account the referrals at (a)-(b) above, and raised at the daily forum his difficulty in being able to see Oliver, it may well have been that Oliver’s case would have merited a more urgent response from the care coordinator or someone else in his stead.
Having heard evidence at the inquest from your Trust’s Clinical Director, ████████, I was not satisfied that the Trust has fully recognised the above shortcomings, and taken action to ensure that they are not repeated for other mental health patients in custody at HMP Hewell.
” 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 Require daily meetings to identify absent care-coordinator patients, assign temporary responsibility, and document handovers and rationale in minutes and SystmOne, with induction and attendance requirements.
Verbatim wording from the response “A standing agenda item of “Provision of Care to Patients in the Absence of Care Coordinator” was added to the Daily Meeting standing agenda. This ensures continuous care for all patients, regardless of staff availability. When a patient concern is raised during these meetings and the assigned care coordinator is absent, the issue is thoroughly discussed among the present team members. A specific worker is then designated to address the concern and assume temporary responsibility for the patient's care. This handover of responsibility is formally documented in the meeting minutes and the patient’s SystmOne record along with rationale. New staff members are introduced to this process during their induction, with details available in the induction folder, and all team members are required to attend these daily meetings.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 Reinforce reviewing recent electronic patient-record activity before assessment or intervention through incident-meeting messages, governance dissemination, management reminders and supervision.
Verbatim wording from the response “The importance of staff familiarising themselves with recent clinical activity from the electronic patient record has been highlighted to all Inclusion staff as part of the key messages that arise from our monthly Health in Justice Serious Incident Meeting.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 Ensure TAG referrals and healthcare applications are added to and visible in SystmOne.
Verbatim wording from the response “There is also now, a clear process for the management of TAG referrals and Healthcare applications ensuring that they are added to and visible in SystmOne.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 Embed continuity-of-care arrangements for planned and unplanned staff absence, including guidance, multidisciplinary discussion and joint daily huddles.
Verbatim wording from the response “There is now also a process embedded within the service to ensure continuity of care during planned and unplanned staff absence. This is set out in the MPFT guidance called “Reallocation when staff are leaving and when absent for 2 weeks or more”. Patients of concern are also discussed within our multidisciplinary forums, both internally within our service, and at joint daily huddles that are now in place led by Practice Plus Group.” Source location Response from Midlands Partnership NHS Foundation Trust
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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 Document patient concerns in SystmOne so subsequent staff can identify raised concerns and plan care and treatment to mitigate risk.
Verbatim wording from the response “Following Mr Davies death, all MPFT colleagues at HMP Hewell have participated in specific clinical supervision focused on the importance of listening to and responding to prisoner concerns. To further support this, the team holds daily team meetings, monthly business meetings, weekly healthcare huddles, and weekly Safety Intervention Meetings (SIM) meetings; all of which have recorded minutes where prisoners' concerns are addressed. Information from the SIM meetings is disseminated to care coordinators via email, ensuring that tasks arising from these discussions can be actioned promptly. All patient concerns are documented on SystmOne by the person who is notified of the concern so that anyone looking at the” Source location Response from Midlands Partnership NHS Foundation Trust
Open published response
12 Aug 2024 Mr Parminder Singh Sanghera · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to conduct a full Mental Health Act assessment before release from hospital or custody View source Failure of hospital and police custody risk assessments to identify suicide or self-harm risk before release View source
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
Mr Parminder Singh Sanghera · 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
Mr Parminder Singh Sanghera was arrested after displaying erratic behaviour, including running naked, and was taken to hospital before being held in police custody. He was released without charge on 13 February 2023 and was later found deceased in a canal near the custody suite. The principal concern was that, despite his behaviour and vulnerability, no full mental health assessment was undertaken before his release and risk assessments did not identify a risk of suicide or self-harm.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a full Mental Health Act assessment before release from hospital or custody
Wider context from the report “1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station .
2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release. However, evidence at the inquest showed that he was suffering from a mental health crisis at the time.
3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release . Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and police custody risk assessments to identify suicide or self-harm risk before release
Wider context from the report “1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station.
2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release . However, evidence at the inquest showed that he was suffering from a mental health crisis at the time .
3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release. Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody.
” Open source report
Concerns raised 12 Failure to provide formal written LDS mental health assessments to police View source Lack of a documented LDS mental health plan for custody View source Unavailability of appropriate LDS-police liaison templates View source Lack of local or national procedures for obtaining mental health assessments during intoxication View source Difficulty obtaining collateral mental health information from other services View source Failure of LDS and police information sharing about custody mental health presentation View source Unavailability of a 24-hour LDS service in custody View source Lack of formal police documentation of family concerns about mental health deterioration View source Lack of formal written handovers of mental health presentation between police officers View source Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals View source Lack of formal documentation procedures for LDS and police custody care View source Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal written LDS mental health assessments to police
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented LDS mental health plan for custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody .
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriate LDS-police liaison templates
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local or national procedures for obtaining mental health assessments during intoxication
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated , a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty obtaining collateral mental health information from other services
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of LDS and police information sharing about custody mental health presentation
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest , was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed ). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a 24-hour LDS service in custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal police documentation of family concerns about mental health deterioration
Wider context from the report “2. Lack of relevant Documentation by the Police
Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal written handovers of mental health presentation between police officers
Wider context from the report “1. Lack of effective Communication between police officers
The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as Miles who was not known to the police. Prior to and at the time of his arrest he was recognised by members of the public and the arresting police officers as showing significant signs of disturbance in his mental health with incongruent speech, inappropriate behavioural affect, and delusional beliefs such as thinking he was playing ‘Grand Theft Auto’ whilst driving recklessly, on a background of intoxication. The extent and the severity of his mental health difficulties was not adequately conveyed through standard ‘word of mouth’ communication between police officers , complicated by Mr Hurley appearing to be more contained and less obviously mentally unwell in custody.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal documentation procedures for LDS and police custody care
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures , or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Custody Pathway Standard Operating Procedure for Sussex Liaison and Diversion services.
Verbatim wording from the response “Since assuming responsibility for Liaison and Diversion services in Sussex MPFT has introduced a Custody Pathway - Standard Operating Procedure (SOP). The SOP was written by Operational Managers/clinicians experienced in the delivery of Liaison and Diversion services in Police custody and was implemented in June 2024.” Source location Response from Midlands 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 Add written best-practice guidance for assessing intoxicated people in police custody to the Custody Pathway SOP.
Verbatim wording from the response “In direct response to your concerns raised during the inquest into Mr Hurley’s death regarding the lack of guidelines to support a Liaison and Diversion practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability, MPFT are currently reviewing the Custody Pathway SOP. It has been agreed with the Senior Leadership Team in MPFT Health and Justice Services that written guidelines, regarding assessment of individuals who are intoxicated, are needed for MPFT staff. MPFT Custody Team Leaders are meeting on the 9th October 2024 to review the SOP to add:” Source location Response from Midlands 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 Add a standard template for written information shared with police colleagues to the Custody Pathway SOP.
Verbatim wording from the response “In direct response to your concerns raised during the inquest into Mr Hurley’s death regarding the lack of guidelines to support a Liaison and Diversion practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability, MPFT are currently reviewing the Custody Pathway SOP. It has been agreed with the Senior Leadership Team in MPFT Health and Justice Services that written guidelines, regarding assessment of individuals who are intoxicated, are needed for MPFT staff. MPFT Custody Team Leaders are meeting on the 9th October 2024 to review the SOP to add:” Source location Response from Midlands Partnership NHS Trust
Open published response
20 May 2024 James Furlong and 2 others · Prevention of Future Deaths report Central Criminal Court
View report summary
Concerns raised 6 Failure to maintain and disseminate an adequate intelligence picture View source Failure to provide an adequate and integrated response to identified risk View source Failure to address consequential risks created by inadequate intelligence dissemination View source Failure to provide adequate secondary mental healthcare in prison View source Failure to provide adequate mental healthcare in the community View source Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms 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
James Furlong and 2 others · 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 Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three deaths.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and disseminate an adequate intelligence picture
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate and integrated response to identified risk
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address consequential risks created by inadequate intelligence dissemination
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate secondary mental healthcare in prison
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate mental healthcare in the community
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 Refresh the psychology pathway and update referral criteria.
Verbatim wording from the response “Following the tragic deaths in Forbury Gardens MPFT undertook an internal review; the report summarising the outcome of this internal review was disclosed to the inquest and formed part of the evidence bundle. The internal review identified the need to address psychological care pathways and the management of psychology waiting lists.” Source location Response from Midlands Partnership NHS
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 staff with ongoing training in psychological care, including CBT, DBT, trauma-informed care and co-occurring conditions.
Verbatim wording from the response “Staff have access to an ongoing programme of training which supports our overall Psychological care of people in prisons. This includes learning about Cognitive Behavioural Therapy (CBT), Dialectic Behaviour Therapy (DBT), Trauma Informed care and working with co-occurring conditions.” Source location Response from Midlands Partnership NHS
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 pilot introducing Mental Health and Wellbeing Practitioner roles in Health in Justice services.
Verbatim wording from the response “MPFT have worked with NHS England to develop a pilot of the Mental Health & Wellbeing Practitioner (MHWP) role which is a new role within some Health in Justice services. This role is one of the newer psychological professions. MHWPs are trained to provide low intensity psychological interventions to people with severe and enduring mental health difficulties.” Source location Response from Midlands Partnership NHS
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 Standardise psychological care pathway practice across prisons.
Verbatim wording from the response “Action was taken to refresh the psychology pathway, including updating referral criteria. There has been a further piece of work across the Prisons we work in to standardise practice in regard to psychological care pathways which is due to be completed by the end of August 2024.” Source location Response from Midlands Partnership NHS
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 Employing more psychological practitioners in prisons is not possible because of current budget constraints.
Verbatim wording from the response “MPFT would welcome the opportunity to employ more psychological practitioners in prisons, however given the constraints of our current budgets this is not possible. Close partner relationships with individual establishments enable us to take an active part in Health Needs Assessments and, where indicated, to work with NHS England to develop business case submissions to request additional funding for psychological provision in addition to the actions already taken above.” Source location Response from Midlands Partnership NHS
Open published response
Concerns raised 4 Failure to communicate onward care plans and timescales View source Inadequate exploration of matters affecting suicide risk View source Failure to provide suicide-risk coping and service-contact information View source Failure to complete suicide risk assessments 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
Jamie Peter Norman PILKINGTON · 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
Jamie Peter Norman PILKINGTON died after his vehicle left the road, struck a tree and caught fire in the early hours of 12 March 2023. At the time, he was under the care of Mental Health Services and had been expressing suicidal thoughts. Concerns included failures to complete suicide risk assessments and insufficient exploration and management of issues relevant to his suicide risk during mental health assessments.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate onward care plans and timescales
Wider context from the report “During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.
When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide.
Furthermore, in an appointment on 3rd March 2023
1. Suicidal/self-harm thoughts not explored in detail.
2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life.
3. There was no exploration regarding efficacy/concordance with medication.
4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services.
5. There was no discussion regarding his support network, next of kin etc.
6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.
On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate exploration of matters affecting suicide risk
Wider context from the report “During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.
When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide.
Furthermore, in an appointment on 3rd March 2023
1. Suicidal/self-harm thoughts not explored in detail.
2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life.
3. There was no exploration regarding efficacy/concordance with medication.
4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services.
5. There was no discussion regarding his support network, next of kin etc.
6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.
On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suicide-risk coping and service-contact information
Wider context from the report “During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.
When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide.
Furthermore, in an appointment on 3rd March 2023
1. Suicidal/self-harm thoughts not explored in detail.
2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life.
3. There was no exploration regarding efficacy/concordance with medication.
4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services.
5. There was no discussion regarding his support network, next of kin etc.
6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.
On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete suicide risk assessments
Wider context from the report “During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.
When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide.
Furthermore, in an appointment on 3rd March 2023
1. Suicidal/self-harm thoughts not explored in detail.
2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life.
3. There was no exploration regarding efficacy/concordance with medication.
4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services.
5. There was no discussion regarding his support network, next of kin etc.
6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.
On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed.
” 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 Include families and carers in collaborative safety planning.
Verbatim wording from the response “• Family and carer engagement; ensuring that families and carers are included in safety planning,” Source location Response from Midlands Partnership NHS
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 Explore adding the Safetool safety-planning function to the electronic patient record.
Verbatim wording from the response “We are exploring the addition of the Safetool (safety planning) onto our electronic patient record system to support the electronic completion of this.” Source location Response from Midlands Partnership NHS
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 collaborative safety planning, replacing traditional suicide risk-assessment approaches.
Verbatim wording from the response “MPFT has developed a three-year suicide prevention plan to address the changes in guidance and practice required to move from the traditional risk assessment and management approaches used in suicide to those of collaborative safety planning led by service users. This plan has five key components:” Source location Response from Midlands Partnership NHS
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 Train staff in suicide awareness, risk formulation and collaborative safety planning across the organisation.
Verbatim wording from the response “MPFT has explored the guidance and what this means for clinicians working with those who may be at risk of suicide. It is recognised that the existing FACE risk assessment is no longer indicated for use in suicide as it is not possible to predict suicide due to the dynamic nature of this. There is building evidence of the effectiveness of safety planning in suicide mitigation, which requires the training and roll out of safety planning skills and tools across the whole organisation. By December 2023 we had trained 1281 staff across the trust in suicide awareness training (e-learning), the safety planning training is face to face and is resource intensive to deliver due to ensuring fidelity against the model therefore numbers for this are lower.” Source location Response from Midlands Partnership NHS
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 Failure to complete the FACE risk assessment does not indicate inadequate suicide-risk management because such tools cannot accurately predict suicide or self-harm.
Verbatim wording from the response “While the FACE risk assessment was not completed on this occasion, the purpose of the tool is to guide clinical discussions with service users in order to identify and explore areas of risk. Completion of the FACE risk assessment, and indeed any risk indicator tool is no longer seen as an effective predictor of suicide. This is highlighted in the revised NICE guidance NG225 Self-Harm: assessment, management and preventing recurrence (Sept. 2022), which guides services not to use assessment tools and scales to predict future suicide or repetition of self-harm. Instead, clinicians are to focus the assessment on the person’s needs and how to support their immediate and long-term psychological and physical safety.” Source location Response from Midlands Partnership NHS
Open published response
Concerns raised 5 Failure to carry out scheduled ACCT observations View source Failure to maintain accurate and complete ACCT observation records View source Lack of a collective inter-agency response to learning lessons View source Failure to ensure transfer for psychiatric treatment where required View source Failure to ensure correct levels of observation up to constant watch 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
Martin Samuel WILLIS · 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
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out scheduled ACCT observations
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and complete ACCT observation records
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted . The last correct entry was at 7 am with earlier omissions .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a collective inter-agency response to learning lessons
Wider context from the report “4. Whilst the prison service and the mental health providers have reviewed the circumstances of Mr Willis’s death, I am concerned that there should be a collective and not individual response to ensure that all lessons can be learned . I therefore recommend that there be an inter-agency review between the prison service and mental health services as to the mental health care provided to the late Mr Willis including the evidence at the inquest and the jury’s findings. In so doing, I do not purport to suggest what the outcome of the review should be.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure transfer for psychiatric treatment where required
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure correct levels of observation up to constant watch
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing.
” 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 Discuss reviewing the standard operating procedure for referring and transferring prisoners to establishments with hospital wings.
Verbatim wording from the response “Action 3. In addition to the above actions the Midlands Partnership University NHS Foundation Trust have commenced discussions with NHS England regarding a review of their Standard Operating Procedure concerning the referral of and transfer of prisoners to prison establishments with a hospital wing which was an agreed outcome of the inter-agency review. Completion timescale September 2024.” Source location Response from Midlands Partnership University
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 the inter-agency review of mental health care provided at HMP YOI Stoke Heath.
Verbatim wording from the response “Colleagues from HMP YOI Stoke Heath, Midlands Partnership University NHS Foundation Trust, Shropshire Community Health NHS Trust and North Staffordshire Combined Healthcare NHS Trust met on 29th January 2024, to undertake an inter-agency review as directed in the Regulation 28 Report.” Source location Response from Midlands Partnership University
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 working at HMP YOI Stoke Heath to complete suicide prevention and ACCT training.
Verbatim wording from the response “Action 2. All Midlands Partnership University NHS Foundation Trust staff working in HMP YOI Stoke Heath are required to complete suicide prevention training and also the ACCT training provided by HMP YOI Stoke Heath. Completion timescale July 2024.” Source location Response from Midlands Partnership University
Open published response
16 Jun 2023 Vaughan Lee WHALLEY · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 5 Failure to assess the risk of suicide or self-harm upon release View source Failure to conduct the conversation in the same room where no practitioner risk was posed View source Failure of operational review to provide substantive scrutiny and identify learning View source Failure to accurately document that an assessment of unmet needs and vulnerabilities had not taken place View source Failure to clearly communicate assessment status to the Police 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. 5
Action
Implement a Health and Justice risk-assessment procedure covering suicide and self-harm assessment, information sharing, Police IT recording, verbal-feedback documentation, and recording declined assessments.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source
Action
Deliver mandatory three-level suicide-mitigation training to Health and Justice clinical staff through e-learning and taught sessions.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2023. View source
Action
Revise the Working in Police Custody procedure to govern observation-hatch assessments and recording of assessment location, participants, rationale, and declined needs assessments.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source
Action
Embed the Patient Safety Incident Response Framework across clinical services through implementation, leadership training, and project-group oversight.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source
Action
Establish independent case-review arrangements and revise the report template to require appropriate comments, observations, learning, and non-duplicative statements.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2023. View source See 2 more actions
×
AI-generated summary
Vaughan Lee WHALLEY · 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
Vaughan Lee WHALLEY was found unresponsive after being released on bail from police custody and died in hospital on 21 February 2023 despite surgery and supportive care. The principal concerns were that no assessment of his risk of suicide or self-harm on release took place, communication to police about any assessment was unclear, and the practitioner’s contact and subsequent review did not meet best practice or identify learning adequately.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the risk of suicide or self-harm upon release
Wider context from the report “(1) No assessment of the risk of suicide or self-harm upon release took place during the Deceased’s time in detention
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct the conversation in the same room where no practitioner risk was posed
Wider context from the report “(3) The conversation between the Practitioner and the Deceased took place through an observation hatch in circumstances where no risk was posed to the Practitioner from being in the same room as the Deceased . This was not best 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of operational review to provide substantive scrutiny and identify learning
Wider context from the report “(5) The ‘review’ undertaken by a Health & Justice Operational Manager of the West Mercia Health & Justice Service consisted of duplication of the Practitioners statement with no comment, observations or identification of areas of learning .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately document that an assessment of unmet needs and vulnerabilities had not taken place
Wider context from the report “(4) The terminology used by the Practitioner was misleading in that it suggested that there was no role for the Liaison and Diversion service because no unmet needs or vulnerabilities had been identified . The evidence was that the Deceased had declined consent for an assessment of unmet needs and vulnerabilities and therefore the notes should have made clear that an assessment of unmet needs and vulnerabilities had not taken place .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate assessment status to the Police
Wider context from the report “(2) There was a lack of clear communication to the Police as to what, if any assessment had taken place .
” 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 Implement a Health and Justice risk-assessment procedure covering suicide and self-harm assessment, information sharing, Police IT recording, verbal-feedback documentation, and recording declined assessments.
Verbatim wording from the response “As a result of the concerns raised we have undertaken a review of the risk assessment processes across our Health and Justice Services. Some inconsistencies in the standards were identified which we have addressed by the development of a Standard Operating Procedure for risk assessment to be applied across Health and Justice Services. The SOP incorporates standards for conducting and sharing risk assessments for people in Police custody. Included in the SOP is a requirement for risk related information to be recorded in the appropriate place in Police IT systems.” Source location Response from Midlands Partnership University NHS Foundation 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 mandatory three-level suicide-mitigation training to Health and Justice clinical staff through e-learning and taught sessions.
Verbatim wording from the response “The revised standards will be supported and embedded by delivery of Suicide Mitigation Training to all clinical staff working in Health and Justice Services.” Source location Response from Midlands Partnership University NHS Foundation 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 Working in Police Custody procedure to govern observation-hatch assessments and recording of assessment location, participants, rationale, and declined needs assessments.
Verbatim wording from the response “Following a review, the Health and Justice Services SOP ‘Working in Police Custody’ has been revised to include guidance for staff on the circumstances under which it is appropriate to review somebody through an observation hatch and the process for recording where and with whom an assessment took place and the rationale for conducting an assessment through an observation hatch if this was necessary. The SOP will be ratified at the MPFT Policy and Procedures Committee on the 09/08/23. I will forward a copy of the SOP as soon as it has been ratified.” Source location Response from Midlands Partnership University NHS Foundation 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 Embed the Patient Safety Incident Response Framework across clinical services through implementation, leadership training, and project-group oversight.
Verbatim wording from the response “MPFT will be transitioning to the new Patient Safety Incident Response Framework (PSIRF) in September 2023. PSIRF will provide improved support for those involved in undertaking investigations improving the safety of the care we deliver to people; the quality of reports produced and supporting shared learning to maximise improvements in healthcare.” Source location Response from Midlands Partnership University NHS Foundation 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 independent case-review arrangements and revise the report template to require appropriate comments, observations, learning, and non-duplicative statements.
Verbatim wording from the response “As a result of the concerns raised regarding the quality of the review undertaken by the Operational Manager we have made a number of changes.” Source location Response from Midlands Partnership University NHS Foundation Trust
Open published response
Concerns raised 4 Lack of training for call handlers View source Failure to act adequately on information received from callers View source Failure of advising colleagues to speak directly with callers View source Failure to discuss cases with callers while accepting information from them 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
Liam Joseph LYES-WATSON · 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
Liam Joseph LYES-WATSON was found deceased on 26 October 2021 in Shrewsbury, Shropshire, with no suspicious circumstances or evidence of third-party involvement. He had been struggling with his mental health and had contact with the Access Team before his death. Concerns included the second call handler’s lack of training, the response to information provided by Liam’s step-father, whether more should have been done, and whether incoming calls should be recorded.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for call handlers
Wider context from the report “(1) Four areas of concern are;
a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller.
b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him.
c. With that information more should have been done.
d. Consideration should be given whether incoming calls to the Access Team should be recorded.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act adequately on information received from callers
Wider context from the report “(1) Four areas of concern are;
a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller.
b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him.
c. With that information more should have been done.
d. Consideration should be given whether incoming calls to the Access Team should be recorded.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of advising colleagues to speak directly with callers
Wider context from the report “(1) Four areas of concern are;
a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller .
b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him.
c. With that information more should have been done.
d. Consideration should be given whether incoming calls to the Access Team should be recorded.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss cases with callers while accepting information from them
Wider context from the report “(1) Four areas of concern are;
a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller.
b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him .
c. With that information more should have been done.
d. Consideration should be given whether incoming calls to the Access Team should be recorded.
” 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 Deliver suicide-prevention training to all Access Team call handlers, record completion, monitor compliance through supervision, and include annual training in mandatory records.
Verbatim wording from the response “We have reviewed the suicide prevention awareness training for call handlers and the decision has been made that all call handlers will have received the training below by the end of November 2022 https://www.zerosuicidealliance.com/training. A record of who has received this training will be held by the team manager and compliance monitored through supervision. In addition to this training, it has been agreed by the service manager that the training offered by Shropshire Council’s Joint Training in Suicide Prevention Awareness Suicide prevention | Shropshire Council is undertaken by all call handlers in the Access Team on a yearly basis and that this is built into their mandatory training for recording purposes on their electronic staff record.” Source location Response from Midlands 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 new call handlers to shadow trained colleagues, receive supervised-call experience, and be assessed as competent before independent work.
Verbatim wording from the response “We have reviewed the training needs for all call handlers. All new call handlers will only shadow trained colleagues until they have completed their training and then will be supervised whilst taking calls until assessed as competent by the Quality Lead.” Source location Response from Midlands 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 call-handler supervision, maintain mandatory-training compliance, and address identified learning needs through monthly Quality Lead meetings.
Verbatim wording from the response “The Call Handler has discussed in supervision meetings with the Quality Lead of the Access Team on a monthly basis since the Serious Incident. All concerns regarding their working practice have been addressed. These meetings also ensure all Mandatory Training is up to date and learning needs have been addressed. These meetings have led to the following further training:” Source location Response from Midlands 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 Reinforce that family concerns require referral to the shift coordinator and that coordinators must speak with relatives to clinically formulate behavioural changes.
Verbatim wording from the response “• We have reinforced to all call handlers that concerns raised by family members are of high significance and must be referred to the shift co-ordinator. We have stressed the importance to all shift co-ordinators that, where family are expressing concerns, they must speak to them to clinically formulate the changes in behaviours.” Source location Response from Midlands 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 the call handler with Stress and Resilience and Zero Suicide Alliance training.
Verbatim wording from the response “• The Call Handler has attended a Stress and Resilience course to help them understand how to manage their own emotional responses to difficult calls received during their work.” Source location Response from Midlands 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 carers’ confidentiality guide with Access Team staff and reinforce appropriate information-gathering and support through team meetings.
Verbatim wording from the response “We have shared MPFT’s Guide to Carers Confidentiality with all the staff in the Access Team. This reinforces the message to our staff that a confidentiality breach only occurs when new, person identifiable, information is given to a third party and does not exclude gathering information from carers and providing them with support and advice. This message has been reinforced in team meetings in October 2022.” Source location Response from Midlands 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 the newly published carers’ confidentiality guide and undertake Triangle of Care training for Access and Crisis Team staff.
Verbatim wording from the response “• The Call Handlers have been provided with MPFT’s newly published Guide to Carers Confidentiality and are awaiting the Triangle of Care Training that all staff on the Access and Crisis Teams will be undertaking to enhance their skills when communicating with family members in contact with their teams.” Source location Response from Midlands Partnership NHS Trust
Open published response
21 Apr 2021 Susan Janet ADAMS · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Janet ADAMS · 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
Susan Adams was found dead in a hotel in Sutton Coldfield on 4 November 2020 after being unable to live at her home in Tamworth. Her death resulted from the consequences of excessive alcohol consumption, with the inquest recording combined toxicity of ethanol, pregabalin and fentanyl with hepatic cirrhosis and steatosis. The report raised concerns about commissioning difficulties affecting access to regular secondary psychiatric care because her home address and GP practice were in different counties.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care
Wider context from the report “Mrs Adams and her family lived in Dosthill, Tamworth, Staffordshire. I was told that this was approximately 50 feet from the border with Warwickshire (and not far from West Midlands as well) and that her GP Practice was in Kingsbury Warwickshire. She needed regular psychiatric assistance from secondary mental health services and I was advised there were significant commissioning difficulties with this because of the home address and GP Practice being in different counties . Mrs Adams could access the crisis team in Staffordshire but long term treatment was supposedly to be provided in Warwickshire . This may have impacted on the care that Mrs Adams received and could be relevant for others who live close to county boundaries. I wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances.
” 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 Forward the county-boundary care concern to commissioners for consideration.
Verbatim wording from the response “However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.” Source location 2021-0116-Response-from-St-Georges-Hospital_Published
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 considering the cross-boundary care arrangements and any resulting action.
Verbatim wording from the response “However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.” Source location 2021-0116-Response-from-St-Georges-Hospital_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing collaborative arrangements between providers ensure people living near county boundaries are not disadvantaged in accessing services.
Verbatim wording from the response “Throughout all of Mrs Adams’ episodes of care, including that in 2020, MPFT has worked well with partners to ensure people living on the county border are not disadvantaged in terms of services offered and in delivering patient-centred collaborative working between organisations.” Source location 2021-0116-Response-from-St-Georges-Hospital_Published
Open published response
Concerns raised 9 Failure of district nurses to involve Tissue Viability Nurses View source Failure to record district nurse visits View source Failure to provide pain relief View source Insufficient GP involvement View source Failure of the band 4 nurse to escalate the seriousness of the situation View source Lack of wound treatment assessment charts View source Failure to keep the pressure mattress switched on View source Failure of nursing notes to clearly record positioning and changes to ulcers View source Failure to check pressure areas View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mavis May Lawrence · 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
Mavis May Lawrence, who had severe dementia and required full nursing care, was admitted to hospital with dehydration, deep ungradable pressure sores and a buttock abscess, and later died on 28 February 2019. The inquest concluded that she died from natural causes exacerbated by infected pressure sores. Concerns included gaps in pressure-area checks and care documentation, a pressure mattress being turned off, lack of escalation and pain-relief evidence, insufficient GP involvement, and district nurses not involving tissue viability nurses.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of district nurses to involve Tissue Viability Nurses
Wider context from the report “(8) District nurses had not involved Tissue Viability Nurses .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record district nurse visits
Wider context from the report “(5)No record of last visit by district nurses on the 27.1.19
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide pain relief
Wider context from the report “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP involvement
Wider context from the report “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved . .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the band 4 nurse to escalate the seriousness of the situation
Wider context from the report “(6)There was no evidence that band 4 nurse escalated the seriousness of the situation .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of wound treatment assessment charts
Wider context from the report “(2)No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the pressure mattress switched on
Wider context from the report “(4)The pressure mattress had been turned off on the 22.1.19
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing notes to clearly record positioning and changes to ulcers
Wider context from the report “(3)Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check pressure areas
Wider context from the report “(1)Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes.
” 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 additional wound-care documentation training and verify staff completion through training-register checks.
Verbatim wording from the response “(1) Nursing notes evidence that pressure areas (sacrum/buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes.
We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c).” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 whether the pain-assessment process is embedded in clinical practice.
Verbatim wording from the response “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved.
Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.).” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 Raise multidisciplinary-team awareness of involving GPs in ongoing patient care.
Verbatim wording from the response “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved.
Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.).” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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, update and relaunch the pain-assessment tool for clinical staff.
Verbatim wording from the response “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved.
Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.).” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 nursing documentation and pressure-ulcer management, using a developed audit tool and reporting findings to senior management.
Verbatim wording from the response “(1) Nursing notes evidence that pressure areas (sacrum/buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes.
We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c).” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 Records show wound assessments occurred after 18 December 2018, consistent with the Trust’s fortnightly assessment guidance.
Verbatim wording from the response “(2) No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas.
There is evidence in the deceased’s records that wound assessments were undertaken after the 18.12.2018. Wound assessments were completed on the 01.01.2019 and on the 27.01.2019 clearly documenting the condition and anatomical location of the wounds. The MPFT guidance is that wound assessments need to be carried out and documented on a fortnightly basis. If the wounds deteriorate before the next fortnightly review, a wound assessment will be completed prior to that date. Records show that in between the regular wound assessments there were regular summaries of the condition of the wounds. Up until the date of admission to hospital the records” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 District nurses are skilled in wound management and refer to tissue viability specialists when wounds deteriorate, consistent with Trust policy.
Verbatim wording from the response “(8) District nurses had not involved Tissue Viability Nurses.
The district nurses and assistant practitioner band 4 assistant practitioners are skilled in managing wounds; including pressure ulcers.” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 Records show the band 4 nurse appropriately escalated the situation to the district nurse team and tissue viability team.
Verbatim wording from the response “(6) There was no evidence that band 4 nurse escalated the seriousness of the situation.
There is evidence in the records that the band 4 nurse escalated this appropriately and notified the nurse in charge of the district nurse team, as well as the tissue viability team, on Sunday 27th January 2019.” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 residential home is responsible for ensuring the pressure mattress is used appropriately.
Verbatim wording from the response “(4) The pressure mattress had been turned off on the 22.1.19
The Residential Home is responsible for ensuring appropriate use of the equipment. Our records show that during a routine visit on 22.1.19 the district nurse noticed that the pressure mattress had been turned off, and took immediate action and turned it back on.” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
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 Residential home carers are expected to conduct regular skin checks and contact district nurses when concerns arise.
Verbatim wording from the response “(5) No record of last visit by district nurses on the 27.1.19
When the patient is cared for in a residential home, the carers are expected to carry out regular skin checks as they are tending to the patient, on a regular basis. The process in place requires that the care staff raise concerns to the district nurses as and when required. There is evidence in the care records that MPFT staff did request the Residential Home staff contact MPFT district nursing staff if they had any concerns. There is evidence of a wound assessment table having been completed by the assistant practitioner (band 4 nurse from the district nursing team) on 27.1.19, in the My Care File when the assistant practitioner (band 4 nurse from the district nursing team) was requested by the Residential home care staff to complete an assessment.” Source location 2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Open published response
Concerns raised 6 Lack of regular searches of the garden View source Failure to maintain garden planting that prevents concealment of dangerous and contraband items View source Failure to secure the ward against patients obtaining drugs within it View source Absence of CCTV coverage of the garden area View source Failure to prevent patients from climbing over the Laurel Ward garden perimeter fence View source Failure to observe patients in the garden unless eyesight observations are required 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
Lee William Davies · 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
Lee William Davies, a detained patient, absconded from a mental health ward on 17 June 2019 and was found unconscious the following day after an out-of-hospital cardiac arrest. He died in hospital on 18 June 2019 after treatment was withdrawn; the inquest recorded a brain injury caused by illicit drug use. Concerns included the reduction of his observation levels despite his risk of absconding to obtain drugs, and ward-garden planting and monitoring arrangements that could allow drugs or other items to be concealed.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular searches of the garden
Wider context from the report “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am;
(2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair;
(3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence.
(4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair.
(5) The deceased was admitted to the Centre with a known substance abuse problem;
(6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure;
(7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use;
(8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015.
(9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants;
(10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage;
(11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken;
(12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded . The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding.
(13) There was no evidence that the garden was searched on a regular basis , patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area.
(14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain garden planting that prevents concealment of dangerous and contraband items
Wider context from the report “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am;
(2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair;
(3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence.
(4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair.
(5) The deceased was admitted to the Centre with a known substance abuse problem;
(6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure;
(7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use;
(8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015.
(9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants;
(10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage ;
(11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken;
(12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding .
(13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area.
(14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure the ward against patients obtaining drugs within it
Wider context from the report “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am;
(2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair;
(3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence.
(4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair.
(5) The deceased was admitted to the Centre with a known substance abuse problem;
(6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure ;
(7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use;
(8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015.
(9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants;
(10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage;
(11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken;
(12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding.
(13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area.
(14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of CCTV coverage of the garden area
Wider context from the report “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am;
(2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair;
(3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence.
(4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair.
(5) The deceased was admitted to the Centre with a known substance abuse problem;
(6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure;
(7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use;
(8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015.
(9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants;
(10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage;
(11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken;
(12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding.
(13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area .
(14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent patients from climbing over the Laurel Ward garden perimeter fence
Wider context from the report “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward . The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am ;
(2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair;
(3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence.
(4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair.
(5) The deceased was admitted to the Centre with a known substance abuse problem;
(6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure;
(7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use;
(8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015.
(9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants;
(10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage;
(11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken;
(12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding.
(13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area.
(14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to observe patients in the garden unless eyesight observations are required
Wider context from the report “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am;
(2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair;
(3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence.
(4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair.
(5) The deceased was admitted to the Centre with a known substance abuse problem;
(6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure;
(7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use;
(8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015.
(9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants;
(10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage;
(11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken;
(12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding.
(13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations , and there was no CCTV covering the garden area.
(14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients.
” 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 Remove the lower portion of the day-room window film to improve visibility into the garden while retaining upper-level privacy screening.
Verbatim wording from the response “2. The second point relates to a ‘film’ which is covering the windows in the day room which looks out onto the garden. This film has been installed for privacy against overlooking houses close to the ward perimeter and to reduce glare into the day room. However, it was highlighted that this can impact on observations into the garden from the day room and therefore, the film will be removed at a lower level (to allow for unhindered vision into the garden) and kept at a higher level (to enable privacy to be maintained and continue to limit glare).” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
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 police search-dog support to search garden areas when needed through established police liaison arrangements.
Verbatim wording from the response “In addition to this, we have established good links with our colleagues at West Mercia Police as part of our police liaison meetings. This has provided us with access to police search dogs on request which has proved to be very beneficial and supportive. Whilst this is a service we cannot always guarantee, we are able to draw on their services to undertake searches of the garden area when there is a need to.” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
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 fence structure and assess replacement or anti-climb retrofit options using quotes and evidence from an existing installation.
Verbatim wording from the response “3. The third point relates to the fence itself. We are in the process of reviewing the fence structure itself and have obtained quotes in the meantime to establish options. One option is to install a full replacement fence and the other option is to retrofit an addition to the existing fence of a 'bull-nose' anti-climb dome along the perimeter. This piece of work will require time to implement as we would want to see a site where this has been previously done and evidence that there are benefits and improvements relating to reducing abscond incidents. If this were the case, we would look to replicate this upgrade across our other two acute wards on the Redwoods site for consistency.” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
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 scheduled frequency for narcotics-dog searches of ward garden areas.
Verbatim wording from the response “Regular searches of the garden area
MPFT employs a Narcotics Search Dog Handler and on request we have used this resource as a way to search areas such as gardens. Whilst this is currently on a more reactive basis, we are discussing ways in which searches can be completed at set frequencies such as bi-monthly whereby a different ward is searched within a set period.” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
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 and document the Laurel Ward garden safety review, including identified environmental risks and remedial actions.
Verbatim wording from the response “Since receiving this action, a review of the garden on Laurel Ward was carried out on the 2nd November 2020 by ████████ (Clinical Matron for Adult Inpatient Services), ████████ (Head of Health, Safety and Security) and ████████ (Health, Safety and Security Manager).” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
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 Move the perimeter-adjacent bench to a safer location within the garden.
Verbatim wording from the response “1. The first point for action was a bench which currently sits close to the perimeter. Whilst this is bolted down, it could be used as a base to attempt to scale the fence and therefore, this will be moved away from the fence to a more suitable location within the garden.” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing garden foliage is considered sufficient because it balances concealment risk and reduces access to the fence.
Verbatim wording from the response “Following our review on the 2nd November, we are satisfied that the garden is maintained in such a way that it is therapeutic to service users and balances the risk of being able to conceal objects as any objects hidden by service user’s would have to be brought through the ward first. This review found that the presence of the foliage impedes service user’s access to the fence thus reducing the ability to scale it.” Source location 2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
Open published response
19 Nov 2019 Andrew Peter Wells · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to apply the Mental Health Act appropriately to informal patients who are effectively detained View source Lack of robust and effective root cause analysis of serious incidents View source
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
Andrew Peter Wells · 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
Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the Mental Health Act appropriately to informal patients who are effectively detained
Wider context from the report “2. The expert witness also stated the Mental Health Act was not applied appropriately. Namely, whilst Mr Wells was technically an informal patient, the clinicians recognised that he would be detained if he tried to leave i.e. he was ‘de-facto’ detained without additional resources and safeguards applicable to a detained patient being put in place. The expert witness said ‘de-facto’ detention was contrary to the Code of Practice to the Mental Health Act and Mr Wells should have been detained. Therefore, my on-going concern is that the Trust’s clinicians are not applying the Mental Health Act 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust and effective root cause analysis of serious incidents
Wider context from the report “1. The Trust’s Internal Root Cause Analysis investigation reviewed the decision making of the clinicians including the role of the treating consultant psychiatrist, the unit’s Responsible Clinician. However, on one on the investigation team was a psychiatrist, or of a similar status to the Responsible Clinician. The RCA report agreed with the Responsible Clinician that the decision making around Mr Wells’ informal status and observation levels was appropriate. The draft RCA report went through a governance exercise, and a member happened to be a consultant psychiatrist, but this did not involve scrutiny of the evidence. I agreed with the evidence from an independent expert consultant psychiatrist that the decision making of the clinicians, including the Responsible Clinician, was not appropriate. Therefore, my on-going concern is that the Trust’s RCA process is not robust or effective enough to learn lessons from serious incidents.
” Open source report
11 Sep 2019 Maureen Margaret Jarvis · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Lack of a clear policy for physical health examination of admitted psychiatric patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maureen Margaret Jarvis · 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
Maureen Margaret Jarvis was detained at the George Bryan Centre and taken to hospital on 15 August 2018, where she died on 17 August 2018 from the effects of a burst ulcer. The report raised concerns that she did not receive a full physical examination during her admission, and also identified issues with record-keeping and the level of personal care.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear policy for physical health examination of admitted psychiatric patients
Wider context from the report “During her final admission to the George Bryan Centre Mrs Jarvis did not have a proper medical examination by a doctor. The reasons given for this were that she would not consent and that her condition never warranted this being done on a non-consensual basis. Among other witnesses I heard helpful evidence from the Consultant Psychiatrist ████████ who indicated that this was a difficult area and also from ████████ (the lead author of the Serious Incident Review) who believed there was a policy about this but could not be specific . It strikes me that there should be a clear policy about physical health examination of admitted psychiatric patients and this should be disseminated to all staff involved.
” 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 Disseminate the physical-health policy and SOP to mental-health inpatient staff and incorporate them into local and junior-doctor inductions.
Verbatim wording from the response “admission. These documents are currently due for review as part of the continuous improvement and ratification cycle. Following changes in recording of investigations in our electronic health record system further guidance was developed to sit alongside these SOP’s. I can confirm that these documents have been circulated to all the staff on our mental health inpatient wards and are being referenced in new inpatient staff local inductions.” Source location 2019-0357-Response-by-Midland-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 guidance alongside the physical-health policy and SOP to support recording investigations in the electronic health record.
Verbatim wording from the response “In response we can confirm that a policy and Standard Operating Process (SOP) existed at the time of Mrs Jarvis’s death. These outline the responsibilities and expectations of inpatient staff to undertake physical health investigations on admission and also the expectation in the circumstance of refusal to consent to continue to attempt during the” Source location 2019-0357-Response-by-Midland-Partnership-NHS-Trust
Open published response
18 Jul 2019 Lindsey Bailey · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure to share relevant information with consenting parents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lindsey Bailey · 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
Lindsey Bailey was found dead by her father in the garage of her home on 14 January 2019 after hanging herself. She had recently engaged with psychiatric services, and the principal concern was that relevant information was not sufficiently shared with her parents despite her capacity and agreement to information sharing, which could have assisted her treatment path.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information with consenting parents
Wider context from the report “At relevant times Ms Bailey did have mental capacity and was in agreement with information being shared with her parents. Reference was made to the Care Engagement Charter promulgated by the Trust. Despite this it appears that there was a significant lack in relevant information being shared with Ms Bailey’s parents . While this may not have necessarily have prevented the death it could have assisted in the treatment path and certainly may be relevant in other cases.
” 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 and implement a standard family and carer letter template within mental health pathway assessment procedures.
Verbatim wording from the response “1) To develop a standard letter template which is sent out to families and carers whose family member have agreed for contact to be made. The letter will form part of our Standard Operating Procedures for assessment across our Mental Health Pathways and each letter will be modified to reflect the individual needs of the patient and their family member.” Source location 2019-0235-Response-by-Midland-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 and roll out a Crisis Response Home Treatment Carer Engagement Standard Operating Procedure across mental health pathways.
Verbatim wording from the response “2) As part of the work to improve Carer Engagement the Trust is in the process of developing a Carer Engagement Standard Operating Procedure for Crisis Response Home Treatment Services which details the standards expected in respect of holding conversations with patients around family and carer involvement at first contact, and this then to be re-visited at every future appointment with the patient to ensure opportunities are not missed. Once developed this will be rolled out across all” Source location 2019-0235-Response-by-Midland-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 Patient confidentiality and her expressed wish not to share all information limited the extent of family involvement.
Verbatim wording from the response “We have considered carefully the difference between confidentiality whilst a patient has capacity versus the engagement of families or carers where the patient has declined for their information to be shared. We acknowledge that as a Trust we need to ensure all our staff are actively embedding family involvement within their daily practice whilst maintaining confidentiality. Whilst carer / family involvement (including gaining informed consent to share information with families) is written into all of our Standard Operating Procedures for assessment, we have identified that clear guidance and advice in engaging with families where the patient has declined for information to be shared is required.” Source location 2019-0235-Response-by-Midland-Partnership-NHS-Trust
Open published response
16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 5 Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly View source Failure to ensure healthcare attendance or input at ACCT reviews View source Inadequate advance notification and information sharing for ACCT reviews View source Failure to review in-possession medication risk assessments when risk changes View source Inadequate cell searching and collection of in-possession medication after a change of risk View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Davey · 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
Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication . It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment . It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary .
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure healthcare attendance or input at ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews . This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available . The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive. It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer. For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate advance notification and information sharing for ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive . It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer . For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review in-possession medication risk assessments when risk changes
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself . I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed . I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate cell searching and collection of in-possession medication after a change of risk
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened . I did not hear much evidence about practice or policies relating to searching and potentially removing medication . This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” 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 Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Verbatim wording from the response “Response:
As was stated at the inquest, our prescriber’s always record on the prescription form whether the medication they are prescribing should be held in possession. We have reminded our staff to ensure when they are reviewing any medication that they, where necessary, include an update of the ‘Medication In possession risk assessment’ which goes onto SystmOne, which in turn will feed into the ACCT. This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held.” Source location 2019-0267-Response-by-Midlands-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 Work with Care UK, Pharmacy and Safer Custody on medication reviews and stop checks under the ACCT procedure.
Verbatim wording from the response “As part of the ACCT LOP we are committed to working with colleagues in Care UK, Pharmacy and Safer Custody regarding medication reviews and “stop checks”.” Source location 2019-0267-Response-by-Midlands-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 escalation procedures with Care UK and the prison for occasions when healthcare cannot attend an ACCT review.
Verbatim wording from the response “The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance.
We will actively contribute to quality assurance checks of compliance with this Local Operating Policy including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks. In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review.” Source location 2019-0267-Response-by-Midlands-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 Work with Care UK and the prison to support healthcare attendance at ACCT reviews and maintain improved attendance processes.
Verbatim wording from the response “Response:
We continue to work with colleagues in Care UK and the prison to ensure we support attendance at ACCT reviews and maintain the improved processes. We comply with the Care UK Local Operating Policy for Healthcare and Subcontracted teams input into the ACCT process.” Source location 2019-0267-Response-by-Midlands-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 Contribute to quality-assurance checks of compliance with the ACCT healthcare-input policy, including PROTECT audits.
Verbatim wording from the response “The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance.
We will actively contribute to quality assurance checks of compliance with this Local Operating Policy including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks. In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
Open published response
Concerns raised 4 Failure to accurately record progress notes and risk assessments View source Delays in access to IAPT counselling View source Failure to define the updating and use of risk assessments with progress notes View source Failure of electronic records to preserve and clearly display original entries 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
Name not published · 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
The deceased had a history of mental health issues, self-harm and two suicide attempts, and was in contact with mental health services until the evening of 30 April 2018 before taking her own life the next morning. Concerns included a prolonged delay in accessing IAPT counselling and difficulties with the electronic recording, risk assessment and progress-note systems.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record progress notes and risk assessments
Wider context from the report “2. Risk assessment and progress notes.
a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written.
b) This is distinct from progress notes and/or risk assessments being accurately recorded . It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to IAPT counselling
Wider context from the report “1 Delay in IAPT counselling
a) After ████████ turned 18 she moved to adult mental health services. She had parallel contact with her GP surgery ████████. Shortly before her 18th birthday, according to the MPFT clinical review (page 9 of 33), ████████ was referred to Improving Access to Psychological Therapies (IAPT) by the ████████ Access Team for assessment for psychological therapy or counselling. On the 14th November 2017 (page 12 of 33) it was agreed with ████████ to add her to her GP surgery waiting list for counselling in line with her treatment preference. ████████ remained on the IAPT waiting list for counselling at the time of her death.
b) The evidence at the inquest was that a 3 month time interval would be optimal but in ████████ case, in relation to this GP surgery, 10 months would be the norm . Such a delay is sub-optimal and could have an adverse effect on a patient waiting for counselling to commence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define the updating and use of risk assessments with progress notes
Wider context from the report “2. Risk assessment and progress notes.
a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written.
b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes . Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of electronic records to preserve and clearly display original entries
Wider context from the report “2. Risk assessment and progress notes.
a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted) . If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written .
b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved.
” 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 Redesign IAPT counselling as a locality-based model with increased capacity and flexibility to respond to demand and staffing changes.
Verbatim wording from the response “The revised model eligibility criteria will give the IAPT service increased capacity, enabling greater flexibility with regard to where and when people can be seen. A 3-month transioperiod is currently underway during which a redesign of the IAPT service is taking place, whereby counselling provision will be more consistently provided across the county from a locality based model, which is more efficient and therefore it will be more possible to be flexible in responding to changes in supply of staff to meet changes in demand thus reducing waiting times to within the statutory 18 week target. It is anticipated that once this work is completed, planned within a six month timescale, it will then be possible to keep waiting times within these recommended limits.” Source location Response from Midlands Partnership NHS Foundation 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 Update Rio form guidance to show staff how to find the history of electronic record entries.
Verbatim wording from the response “The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.” Source location Response from Midlands Partnership NHS Foundation 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 the Rio system further to make exact changes between versions of electronic records identifiable.
Verbatim wording from the response “The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.” Source location Response from Midlands Partnership NHS Foundation 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 Update Trust policies and procedures for clinical risk assessment and management, including minimum six-monthly and significant-change reviews.
Verbatim wording from the response “Since we became a new Trust in June 2018 our services have expanded considerably leading to a review of all Trust Policies and Procedures. We are currently updating our policies and procedures for Clinical Risk Assessment and Management. The new policy will go to Trust Board in March 2019 and includes the directive that all risk assessments must be reviewed as a minimum once every six months and/or when there is any significant change in presentation. In addition, to complement the policy, we are developing a number of Standard Operating Procedures (SOPs) for specific services which includes one for mental health services and effective utilisation of the FACE risk assessment tool.” Source location Response from Midlands Partnership NHS Foundation 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 Remind staff to validate records and routinely audit unvalidated notes, providing audit feedback to clinical teams.
Verbatim wording from the response “validated by others. We have issued a reminder to staff to validate their records and a regular audit of un-validated notes is undertaken with feedback of the audit outcome being sent to the clinical teams.” Source location Response from Midlands Partnership NHS Foundation 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 Extend mandatory clinical risk management training to cover the revised mental-health risk assessment and management procedures.
Verbatim wording from the response “The SOP describes how the FACE Tool is used to gather information about risk, both current and historical, and then to use this information in formulation which is an evidence based clinical decision making process enabling a robust risk management plan to be developed specifically addressing the individual patient’s needs. This risk management plan will then be incorporated into the patient’s overall care plan. Monitoring of this care plan is through the patient’s progress notes. When there is a significant change in presentation the risk assessment is re-evaluated, risk management plan updated and reference made to this in the progress notes. In order to ensure that staff are competent in this process, the clinical risk management training, which is mandatory for all clinical staff to complete every 3 years, will cover the revised Standard Operating Procedures.” Source location Response from Midlands Partnership NHS Foundation 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 obtain ratification for a mental-health Standard Operating Procedure covering use of the FACE risk assessment tool.
Verbatim wording from the response “Since we became a new Trust in June 2018 our services have expanded considerably leading to a review of all Trust Policies and Procedures. We are currently updating our policies and procedures for Clinical Risk Assessment and Management. The new policy will go to Trust Board in March 2019 and includes the directive that all risk assessments must be reviewed as a minimum once every six months and/or when there is any significant change in presentation. In addition, to complement the policy, we are developing a number of Standard Operating Procedures (SOPs) for specific services which includes one for mental health services and effective utilisation of the FACE risk assessment tool.” Source location Response from Midlands Partnership NHS Foundation 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 Automatic validation of all electronic records is not achievable because some staff entries must be validated by other staff.
Verbatim wording from the response “In regard to the validation of notes, legally it is only students who must have their records validated by a qualified member of staff. All other staff are required to validate their own entries. The action of validating the entry represents the electronic signature of the accuracy and confirmation of that entry. The Trust has explored with our healthcare information colleagues whether the default could be an automatic validation which is then “unticked” but this is not achievable given that some staff must have their entries” Source location Response from Midlands Partnership NHS Foundation Trust
Open published response
Concerns raised 3 Delays in referral to a dietician for patients losing weight View source Failure to ensure accurate recording of patients’ nutritional intake View source Lack of a policy for referral to mental health services following prolonged social isolation View source
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
Sheila Graham · 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
Sheila Graham was admitted to hospital after a fall causing a complicated ankle fracture, subsequently developed infection and clostridium difficile, and died on 13 October 2017 after an upper gastrointestinal bleed. Concerns included the effects of prolonged isolation on her mental and general wellbeing, inadequate recording and monitoring of nutrition despite weight loss, and delayed referral to mental health and dietetic 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to a dietician for patients losing weight
Wider context from the report “(3) The deceased lost weight. There was no referral to a dietician until prompted by the family.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate recording of patients’ nutritional intake
Wider context from the report “(2) There was evidence that meals were delivered by an independent company called Sodex. The family frequently observed this company giving out and collecting meal trays. Despite this medical records appeared to have been completed daily by nursing and health care staff recording adequate nutrition. Given this situation how is it possible to reconcile the nursing records with the practice of the catering team distributing and collecting meal trays?
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for referral to mental health services following prolonged social isolation
Wider context from the report “(1) At the inquest it was evident that the deceased had suffered with clostridium difficile diarrhoea. It was accepted by the patient and the family that she needed to be nursed in a single room. However in her case it was for a very prolonged period. The social isolation had a very significant impact on her health and well-being and was a factor in her failure to recover. No policy appears to be in place for referral to mental health services in such circumstances. Referral in this case was prompted by the family.
” Open source report
13 Nov 2018 Thomas Paul Arthur JACKSON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 11 Failure of staff to recognise Clozapine significance, side-effects and warning signs of deterioration View source Lack of national policy for regular clozapine blood plasma-level testing View source Unclear lone-working procedures for entering patients’ rooms View source Poor recording of ward rounds or multi-disciplinary team meetings View source Inadequate patient participation in clinical meetings View source Difficulty disclosing significant patient documents during the Inquest process View source Unavailability of standard treatment and Clozapine smoking-risk information for patients and families View source Failure of appropriate personnel to attend clinical meetings View source Poor record keeping affecting continuity of care View source Inadequate consideration of patient history before clinical meetings View source Inaccuracies in serious incident reviews affecting process validity View source See 8 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
Thomas Paul Arthur JACKSON · 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
Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to recognise Clozapine significance, side-effects and warning signs of deterioration
Wider context from the report “(3) It is clear that Clozapine is a beneficial drug for many patients and that a large number of patients in the care of the Trust do receive this drug. However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national policy for regular clozapine blood plasma-level testing
Wider context from the report “It is well known that Clozapine is a potentially dangerous drug which needs to be carefully monitored. Monitoring is for both whole blood to look at infection markers and for blood plasma to cheek on Clozapine levels. Since this death the Trust involves has established a policy for the regular checking of blood plasma levels for patients in receipt of Clozapine. However it appears that this is a local policy and that there is no national policy for these checks to be carried out . I wonder if there should be a direction for all trusts to carryout blood plasma tests on patients receiving Clozapine on a regular basis perhaps at least six monthly or yearly.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear lone-working procedures for entering patients’ rooms
Wider context from the report “(5) I wonder if there needs to be a review of any lone-working policy or procedure with particular reference as to when to enter patients’ rooms .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor recording of ward rounds or multi-disciplinary team meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times , there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate patient participation in clinical meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty disclosing significant patient documents during the Inquest process
Wider context from the report “(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of standard treatment and Clozapine smoking-risk information for patients and families
Wider context from the report “(4) I would not wish for patients or their families to be overloaded with paperwork but I wonder if there could be a simple leaflet available to patients and family members covering standard information about treatment generally but including matters such as the dangers of patients smoking whilst they are receiving Clozapine .
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of appropriate personnel to attend clinical meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping affecting continuity of care
Wider context from the report “(1) During the hearing it was noted that on a number of occasions record keeping was poor . This can make continuity of care difficult and it can lead to matters being missed. I wonder if the Trust can take any action to improve this.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate consideration of patient history before clinical meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting , failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in serious incident reviews affecting process validity
Wider context from the report “(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process . Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process.
” Open source report
Concerns raised 3 Failure to share information between alcohol liaison and inclusion services View source Failure to provide follow-up after emergency department admissions for alcohol-related presentations View source Lack of a coordinated plan to treat alcohol dependence View source
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
Nigel Malloy · 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
Nigel Malloy fell from a second-floor window on 29 October 2017 while intoxicated with alcohol, suffered severe head injuries, and died in hospital two days later. He was alcohol dependent and had depressive symptoms, with previous similar falls and multiple hospital admissions, but concerns were raised that there was no information sharing or coordinated treatment plan between the relevant alcohol-support 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share information between alcohol liaison and inclusion services
Wider context from the report “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide follow-up after emergency department admissions for alcohol-related presentations
Wider context from the report “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up . On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinated plan to treat alcohol dependence
Wider context from the report “The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.
” Open source report
Concerns raised 5 Delays in reporting falls through the incident reporting system View source Failure to maintain up-to-date transfer-of-care information View source Poor communication with relatives View source Failure to conduct nurse-to-nurse discharge communication between hospitals View source Failure to include falls in hospital discharge information View source See 2 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
Kenneth William Horne · 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
Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting falls through the incident reporting system
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date transfer-of-care information
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication with relatives
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct nurse-to-nurse discharge communication between hospitals
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include falls in hospital discharge information
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” Open source report
Concerns raised 6 Failure to recognize suicidal ideation that may be masked by autistic spectrum conditions View source Lack of a mechanism for referring cases back to the consultant psychiatrist View source Failure to provide an urgent medical review after suicidal ideation was identified View source Subjective risk assessments without reference to defined risk criteria View source Failure to provide an effective route for urgently escalating concerns about a delayed mental health appointment View source Lack of knowledge of the deliberate self-harm protocol 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
Jeff David ANTWIS · 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
Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.
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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognize suicidal ideation that may be masked by autistic spectrum conditions
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for referring cases back to the consultant psychiatrist
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an urgent medical review after suicidal ideation was identified
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Subjective risk assessments without reference to defined risk criteria
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an effective route for urgently escalating concerns about a delayed mental health appointment
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the deliberate self-harm protocol
Wider context from the report “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete.
(2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.
(3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it.
(4) On the 30th January 2017 Jeff killed himself on the railway line.
(5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff.
(6) Other matters of concern arose from the evidence. The mental health practitioner:
a) Was aware of the deliberate self-harm protocol but not its content.
b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant.
c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not.
(7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.
(8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review.
” 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 Implement a standardised validated clinical risk assessment tool and pathway for responding to changes in risk.
Verbatim wording from the response “• A single point of access to the service was implemented on 4th Dec 2017 to ensure that young people’s needs can be appropriately identified at the point of referral and an appropriate, timely response provided (point 1 and 7). Introduction of standardised validated clinical risk assessment tool with associated pathway to enable timely robust response to changes in risk level (Also points 2, 3, 5, 6 & 7)” Source location 2017-0392-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 Establish clear care pathways enabling case-holding clinicians to obtain additional psychology, family therapy and consultant psychiatry support.
Verbatim wording from the response “• When a young person is accepted within the service, a clear pathway for their care is identified, this enables the case holding clinician to access additional support for example, psychology, family therapy consultant psychiatry (Also points 2, 3, 6 & 7) Healios are delivering one therapeutic interventions as part of core MH service (point 8).” Source location 2017-0392-Response
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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 Establish escalation processes within clinical pathways to obtain urgent psychiatric reviews when concerns arise.
Verbatim wording from the response “• Escalation processes have been agreed within clinical pathways so that urgent psychiatric reviews can be obtained when concerns are raised (points 2, 4, 5 & 7)” Source location 2017-0392-Response
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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 practitioners’ caseloads and open cases to ensure appropriate care plans, risk assessments and recording of need levels.
Verbatim wording from the response “• We have commenced reviewing the caseloads of all practitioners within the service to ensure that all young people within the service have appropriate care plans and risk assessments in place (points 2, 3, 5, 6 & 7) this will be completed by 31st March 2018.” Source location 2017-0392-Response
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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 Reserve one weekly appointment in each consultant psychiatrist job plan for urgent assessments.
Verbatim wording from the response “• One assessment appointment each week is ring fenced for urgent assessments in each Consultant Child & Adolescent Psychiatrist job plan to ensure that young people presenting in crisis are provided with urgent psychiatric review (points 2, 4, 5 & 7)” Source location 2017-0392-Response
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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 Shropshire Community Health NHS Trust was responsible for investigating care because it provided CAMHS services in Shropshire at the relevant time.
Verbatim wording from the response “As identified in your letter South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not providing CAMHS services within Shropshire at the time of Jeff’s death therefore South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not in a position to have carried out an investigation into the care of Jeff prior to his death. The Serious Incident Investigation presented at the inquest was carried out by Shropshire Community Health NHS Trust who were providing CAMHS services in Shropshire in January 2017.” Source location 2017-0392-Response
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27 Jun 2017 Dean Mark Rowland · Prevention of Future Deaths report Staffordshire South
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Concerns raised 2 Failure to provide follow-up after community mental health assessment View source Delays in access to a GP for medication discussions 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
Dean Mark Rowland · 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
Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide follow-up after community mental health assessment
Wider context from the report “(2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with 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 Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to a GP for medication discussions
Wider context from the report “(1) The deceased wished to discuss an increase in his antidepressant medication with a doctor. He was unable to get an appointment or speak to a GP on the telephone for nine days.
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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 Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.
Verbatim wording from the response “Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be re-referred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future should the need arise. If the assessment had highlighted the need for ongoing input from the CMHT, this would have been transferred to the service in Birmingham local to Mr Rowland’s new residence, but as described it was not required.” Source location 2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
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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 assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.
Verbatim wording from the response “When seen on 19th August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and reported improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing “feel like I have my life back and am like my old self” and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT.” Source location 2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
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Addressed to Staffordshire and Stoke On Trent Partnership NHS Trust, now represented here by Midlands Partnership University NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations