Recipient

Mother of the deceased

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First report 4 Mar 2014•Latest report 4 Mar 2014

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Mother of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Ms. Kimberley Parsons · 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

    Ms. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality disorder.

    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 Mother of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of published evidence supporting assisted self-harming as a treatment approach

    Wider context from the report

    “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research. (2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals. (3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly 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 Mother of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of proper procedures for introducing and using novel treatments

    Wider context from the report

    “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research. (2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals. (3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly 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 Mother of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to discuss proposed treatment with the consultant in charge

    Wider context from the report

    “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research. (2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals. (3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly 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 Mother of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record proposed treatment discussions

    Wider context from the report

    “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research. (2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals. (3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly 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 Mother of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to address identified patient-safety deficiencies at Hillview Lodge

    Wider context from the report

    “(1) That serious deficiencies affecting the safety of patients at Hillview Lodge which had been identified in March 2014 had not been addressed by the Trust by the time of the CQC inspection in June 2014. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026