10 Mar 2017 Lester John STACEY · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 3 Failure to visit and re-engage people who do not respond to appointment contacts View source Failure to monitor medication after changes during admission View source Failure to arrange follow-up appointments before discharge 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.
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AI-generated summary
Lester John STACEY · 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
Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.
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 visit and re-engage people who do not respond to appointment contacts
Wider context from the report “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016.
There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication.
” 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 monitor medication after changes during admission
Wider context from the report “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016.
There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication.
” 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 arrange follow-up appointments before discharge
Wider context from the report “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016.
There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication.
” Open source report
9 Mar 2017 Annabel Mae LEWIS · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 4 Delays between referral, initial contact and attempted follow-up View source Failure to engage parents or other support networks when young people have difficulty engaging View source Failure to record risk, contact details, appointment information and follow-up arrangements View source Failure to provide proactive follow-up after a declined appointment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Annabel Mae LEWIS · 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
Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.
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 between referral, initial contact and attempted follow-up
Wider context from the report “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded.
There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life.
The time period between referral and initial contact and attempted follow up appears considerable.
No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements.
The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging.
Annabel might well have benefitted had she been offered a more proactive service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage parents or other support networks when young people have difficulty engaging
Wider context from the report “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded.
There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life.
The time period between referral and initial contact and attempted follow up appears considerable.
No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements.
The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging.
Annabel might well have benefitted had she been offered a more proactive service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record risk, contact details, appointment information and follow-up arrangements
Wider context from the report “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded.
There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life.
The time period between referral and initial contact and attempted follow up appears considerable.
No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements.
The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging.
Annabel might well have benefitted had she been offered a more proactive service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midlands Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide proactive follow-up after a declined appointment
Wider context from the report “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded.
There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life.
The time period between referral and initial contact and attempted follow up appears considerable.
No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements.
The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging.
Annabel might well have benefitted had she been offered a more proactive service.
” Open source report
24 Dec 2015 Angela Catherine Brealey · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 4 Serious incident reviews failing to identify treatment concerns View source Failure to protect confidentiality of information provided by third parties View source Insufficient involvement of a multi-disciplinary team in care View source Lack of a defined process for acknowledging and recording information received from third parties 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
Angela Catherine Brealey · 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
Angela Brealey was found dead at home on 19 September 2014 after hanging herself. She was receiving treatment from local secondary psychiatric services, but no full assessment by a Consultant Psychiatrist had been carried out. Concerns included the handling and confidentiality of information from third parties, limited multidisciplinary team involvement, and whether pressure on serious incident reviewers reduced the effectiveness of the review.
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 Serious incident reviews failing to identify treatment concerns
Wider context from the report “(3) Generally the serious incident review process is a very helpful one. In this particular case however a number of concerns about Angela’s treatment were not picked up by the review. Is pressure on those carrying out this process reducing the effectiveness of the reports?
” 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 protect confidentiality of information provided by third parties
Wider context from the report “(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided?
” 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 involvement of a multi-disciplinary team in care
Wider context from the report “(2) During the period that Angela was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved.
Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals may have been preferable. Is this something that the Trust needs to look at?
” 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 defined process for acknowledging and recording information received from third parties
Wider context from the report “(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided?
” 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 policy and process for receiving and storing third-party information in RiO, including uploading written communications and recording verbal communications.
Verbatim wording from the response “The Trust now has a clear policy and process for receiving and storing third party information in Rio which is in line with national policy. Lengthy written communications are uploaded to RiO as sent, so are available to the care team and a note made in the progress notes to identify they have been stored and the location. Verbal communication is recorded in progress notes in line with policy.” Source location 2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend the Serious Incident Review Process, with structured internal and external governance arrangements.
Verbatim wording from the response “Thank you for your comments regarding the overall helpfulness of the Serious Incident Review Process. I can confirm that since the time of this specific Serious Incident Review, the process has been reviewed and amended. The Serious Incident Review Process follows a structured and robust process with internal and external governance arrangements in place.” Source location 2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-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 commissioners to conduct a challenge review before signing serious incident reports for release.
Verbatim wording from the response “In addition the reports now go through an additional governance process in that our commissioners carry out a challenge review prior to signing the report off for release.” Source location 2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-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 Employ a full-time Serious Incident Review Co-ordinator and Administrator to support investigations and improve the quality of serious incident reports and reviews.
Verbatim wording from the response “The Trust now employs full-time Serious Incident Review Co-ordinator and Administrator to support Investigating Officers in the review process. The Serious Incident Review Co-ordinator works within the Trust’s Quality and Risk Department to help improve processes that are used to ensure the quality production of reports relevant to serious incidents. They support Investigating Officers in the completion of Serious Incident Reports and Significant Event Reviews and are responsible for the completion of Chronological and concise reports.
The Serious Incident Review Co-ordinator supports and encourages an open and fair approach to incident identification and investigation, supported by a learning culture.” Source location 2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-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 Third-party information cannot be acknowledged where doing so would breach Caldicott confidentiality principles.
Verbatim wording from the response “The Trust may not respond to information from third parties as we adhere to Caldicott Principles in the management of all service user information. Where these principles would be breached the recipient of the information would not acknowledge, to the third party, that the service user was known to the service.” Source location 2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-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 Existing multidisciplinary team oversight and supervision are considered sufficient even when one professional delivers the care plan.
Verbatim wording from the response “The Trust mental health teams are all multi-professional and the model of working within all teams is multi-disciplinary, the care and treatment provided to all service users is overseen by the teams so even in circumstances where a person may be receiving interventions associated with a care plan from a single professional the individual practitioner will be discussing the care with other members of the team in caseload and team supervision.” Source location 2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Open published response
2 Mar 2015 Peter Jonathan Wright · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 4 Lack of out-of-hours doctor cover at the hospital View source Insufficient ward staffing for the patient workload View source Failure to conduct drugs rounds in accordance with the requirement for more than one staff member View source Failure to record all necessary patient observations 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
Peter Jonathan Wright · 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
Peter Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.
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 out-of-hours doctor cover at the hospital
Wider context from the report “(2) At the time of this incident there was still a 24 hour Emergency Department at the nearby Stafford Hospital and at St George’s Hospital there was no doctor on site . Now the Emergency Department at County (formerly Stafford) Hospital is not open during the night and the nearest ED is at Stoke. I was told that the situation can be managed by calling paramedics. While I appreciate that nearly all the doctors at St George’s are psychiatrists not medics I wonder if any consideration has been given to out of hours cover by a doctor?
” 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 ward staffing for the patient workload
Wider context from the report “(1) At the time of the death the ward was understaffed . Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients . She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory .
” 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 drugs rounds in accordance with the requirement for more than one staff member
Wider context from the report “(1) At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy) . This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory.
” 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 all necessary patient observations
Wider context from the report “(1) At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory.
” 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 Conduct nurse staffing establishment reviews at least every six months using quality, workload and professional-judgment data, with recommendations reviewed by the Trust Board.
Verbatim wording from the response “The Trust undertakes nurse staffing establishment reviews for each of our in-patient ward areas on at least a six-monthly basis. In undertaking these reviews, the Trust uses:” Source location 2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
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 non-nursing clinical staff on the ward to undertake duties including therapeutic interventions.
Verbatim wording from the response “with additional staff being deployed to meet any increased acuity. There are also non-nursing clinical staff who will be present on the ward undertaking other duties – examples will include medical and allied health professionals providing therapeutic interventions.” Source location 2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
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 Brocton Ward with a minimum staffing establishment of four, four and three, including two registered nurses on duty at all times, and deploy additional staff when acuity increases.
Verbatim wording from the response “For 2015/16 Brocton Ward staffing establishment is 4/4/3 (with two registered nurses on duty at all times). This is the minimum level which can be expected on the ward” Source location 2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
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 staffing reviews, minimum ward establishments and additional staff deployment are considered sufficient to manage patient acuity and staffing needs.
Verbatim wording from the response “The Trust undertakes nurse staffing establishment reviews for each of our in-patient ward areas on at least a six-monthly basis. In undertaking these reviews, the Trust uses:” Source location 2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
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 Paramedics are considered best placed to provide advanced emergency support and stabilisation before transfer to hospital.
Verbatim wording from the response “Every clinical and non-clinical area has first aid in place and wards are stocked with equipment for managing common emergencies. We do however recognise that more sophisticated medical equipment and support may be required at times, and in the case of a medical emergency we expect staff to call 999 without delay, as this is what people in the community would do in similar circumstances.” Source location 2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
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 Non-resident medical cover, trained staff, emergency equipment, basic life support and 999 access are considered sufficient for out-of-hours medical emergencies.
Verbatim wording from the response “The Trust does not have resident doctors on call but operates a non-resident out of hour’s rota to comply with European Working Time Directive.” Source location 2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
Open published response
Concerns raised 7 Failure to remove a previously identified high-risk belt ligature View source Failure of the sloping door to prevent ligature attachment View source Failure to recognise continuing constant-watch status after transfer View source Delays in transfer before night-shift handover View source Reduced risk awareness from perceived ligature-free ward environment View source Failure of handover to provide sufficient patient knowledge and review time View source Flawed basis for observation-level assessment following information breakdown View source See 4 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
Peter James FAREBROTHER · 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
Peter James Farebrother was found deceased on 24 August 2013, hanging from a belt ligature attached to the en-suite shower door in his room at Pine Ward. Concerns included the delayed transfer to Pine Ward, failures in handover and observation assessment, the return of his belt, and the suitability of the shower door as a ligature attachment point. The inquest jury concluded that the risk of returning his belt and placing him on general observation was not fully recognised and that these factors combined contributed to his death.
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 remove a previously identified high-risk belt ligature
Wider context from the report “(5) The decision to return the belt to Mr Farebrother . It was the same belt which a) Mr Farebrother later hanged himself with and b) had resulted in Mr Farebrother having been on constant observation at Holly Ward . Whilst other ligatures may still have been available to Mr Farebrother by removing the belt the most obvious ligature would have been avoided .
” 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 sloping door to prevent ligature attachment
Wider context from the report “(7) The sloping door was intended to prevent or reduce the risk of hanging . Mr Farebrother’s case has indicated that this is not so . No change has been made to the door and it is therefore possible that this means of ligature attachment could happen again . The door was manufactured and delivered for purpose and therefore this concern should also be shared with the manufacturer. Consideration should also be given whether there is a need for an en-suite shower door, balancing the patient’s rights of privacy and dignity over risk of self-harm.
” 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 continuing constant-watch status after transfer
Wider context from the report “(2) The failure by the receiving staff on Pine Ward a) during the remainder of the evening shift or b) at any time during the night shift to recognise that Mr Farebrother had been on constant watch up to and including the transfer and that no assessment had taken place changing that status .
” 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 transfer before night-shift handover
Wider context from the report “(1) The delayed transfer to Pine Ward coming at the end of an evening shift prior to handover to the night shift .
” 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 Reduced risk awareness from perceived ligature-free ward environment
Wider context from the report “(6) The perception that Pine Ward may be ligature free may have lowered risk awareness . Staff may have felt that the need for higher observation and/or ligature avoidance had been reduced by the environmental safety features on Pine Ward itself, whereas the underlying risk remained .
” 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 handover to provide sufficient patient knowledge and review time
Wider context from the report “(3) The lack of personal knowledge in the handover procedure and the limited time the assessing assistant practitioner had at the start of the morning shift to read Mr Farebrother’s papers .
” 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 Flawed basis for observation-level assessment following information breakdown
Wider context from the report “(4) The assessment may well have resulted in a higher observation level and the basis on which it was made , consciously or subconsciously, may have been flawed by the earlier breakdown in information .
” Open source report
Concerns raised 3 Failure to share significant safeguarding information between concerned professionals View source Failure to refer and assess an adult at risk as a vulnerable adult or victim of domestic violence View source Failure to inform an adult at risk of increased domestic violence risk 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
Christine Ann WILLIAMSON · 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
Christine Ann Williamson, aged 62, died following a physical assault by her husband, who had advanced Alzheimer’s dementia and was unaware of his actions or their consequences. The concerns included the absence of an earlier referral and assessment of her as a vulnerable adult at risk, and inadequate information sharing that might have enabled preventative measures.
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 significant safeguarding information between concerned professionals
Wider context from the report “(2) Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with every having significant information sharing it with others . This would have increased the likelihood that preventative measures would have been put in place as the deceased being better or fully informed as to the increased risk she was putting herself in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical.
” 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 refer and assess an adult at risk as a vulnerable adult or victim of domestic violence
Wider context from the report “(1) A referral and assessment should have been made that the deceased was a Vulnerable Adult at risk from her husband . Such a referral and assessment could have been made before or after April 2012, but most notably on or around the 2nd - 4th April 2012 when the deceased’s GP made a direct referral to social services. This should have led to an assessment as a Vulnerable Adult but if not as the victim of domestic violence .
” 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 an adult at risk of increased domestic violence risk
Wider context from the report “(2) Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with every having significant information sharing it with others. This would have increased the likelihood that preventative measures would have been put in place as the deceased being better or fully informed as to the increased risk she was putting herself in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations