Concerns raised 1 Lack of alternative contact arrangements during Care Coordinator absence View source
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. 2
Action
Implement sickness-absence cover arrangements through the Revised Policy, including patient notification, alternate support, duty-worker escalation, home-visit cover and caseload allocation.
View source
Action
Continue operating the Revised Policy and maintain audited processes for informing new and existing staff about sickness-absence cover arrangements.
View source
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AI-generated summary
Reece William NELSON · 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
Reece Nelson was found hanging at his home address in Grimsby on 28 February 2022 and was pronounced dead by paramedics. His family had tried to contact his Care Coordinator because of concerns about his mental state, but they were not informed that the coordinator was on sick leave and no return call was made.
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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 NAViGO Health and Social Care CIC; that does not assign responsibility.
PFD Monitor interpretation Lack of alternative contact arrangements during Care Coordinator absence
Wider context from the report “On the morning of Reece Nelson's death his family attempted to contact his Care Coordinator due to concerns regarding his mental state. The Care Coordinator was on sick leave, however this information was not reported to the family and therefore no return call was made to them . Had the family been made aware that the Care Coordinator was on sick leave they would have tried alternative routes to contact the mental health services to seek assistance. There should be a system in place whereby alternative contact details are provided in the event of a staff member being absent
” 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 sickness-absence cover arrangements through the Revised Policy, including patient notification, alternate support, duty-worker escalation, home-visit cover and caseload allocation.
Verbatim wording from the response “In the event a Care Coordinator rings in sick or any other sickness absence period, the Team Leader will go through staff diaries and task admin to phone each patient to let them know their worker is off sick, the Team Leader will also determine whether alternate support is required in the absence of their Care Coordinator. In the event other support is required the Team Leader is to liaise with the duty person to arrange this. The team are to be made aware and relevant duties allocated in the morning huddle by the Team Leader. All patients will be made aware that they can contact our duty worker for support at any time during office hours Monday to Friday 9am to 5pm. The duty worker is able to conduct a home visit where needed.” Source location Response from Navigo
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 Continue operating the Revised Policy and maintain audited processes for informing new and existing staff about sickness-absence cover arrangements.
Verbatim wording from the response “5 Navigo will continue to operate in accordance with the Revised Policy and will ensure processes to inform both new and existing staff members of the cover arrangements remain in place and are audited.” Source location Response from Navigo
Open published response
26 Oct 2022 Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 3 Premature closure of the mental health assessment case View source Failure to undertake face-to-face assessment after recent suicide attempts View source Failure to consider Mental Health Act admission criteria View source
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AI-generated summary
Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NAViGO Health and Social Care CIC; that does not assign responsibility.
PFD Monitor interpretation Premature closure of the mental health assessment case
Wider context from the report “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation"
the SW replies
"An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future".
The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA.
Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted.
In addition, the recommendation was for a face-to-face meeting with the deceased.
Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NAViGO Health and Social Care CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake face-to-face assessment after recent suicide attempts
Wider context from the report “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation"
the SW replies
"An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future".
The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA.
Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted.
In addition, the recommendation was for a face-to-face meeting with the deceased.
Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NAViGO Health and Social Care CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to consider Mental Health Act admission criteria
Wider context from the report “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation"
the SW replies
"An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future".
The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA.
Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted.
In addition, the recommendation was for a face-to-face meeting with the deceased.
Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day.
” Open source report
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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 No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.
Verbatim wording from the response “11 NAViGO does not propose to take any action in relation to its systems or processes in response to the concern raised. The response above sets out the rationale for the decision. It followed an assessment of Mr Lippolis in line with nationally recognised practice by two experienced practitioners. The decision was based on Mr Lippolis’ responses and presentation at the time and the professional judgement of the practitioners. For the reasons given above there is, in NAViGO’s judgement, no change to systems or processes that need be made in order to avoid deaths in future. Decisions will always depend on the particular circumstances of each individual assessment.” Source location Response from NAViGO
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 Follow-up after hospital assessment was assigned to local LPFT services, with NAViGO recommending face-to-face contact.
Verbatim wording from the response “6 The only observation made on the second concern is that NAViGO's Hospital Liaison Psychiatric Team contacted the relevant LPFT services after the assessment at the Hospital and requested a face to face follow-up with Vincenzo Joseph Michael Lippolis by his local services (as detailed in the written report of ████████, NAViGO Liaison Practitioner, dated 22 October 2022, provided to the Coroner).” Source location Response from NAViGO
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations