Recipient

NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board

First report 12 Feb 2016•Latest report 7 Aug 2016

Recipient record

Reports, concerns and published responses

Health and care · Integrated care board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 50%
Concerns addressed: 1
Stated actions: 8

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.

50%published responses found

8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Aug2016
Avon
Concerns raised2
1. Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment
2. Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable
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. Rohan Fitzsimons · 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. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.

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 NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment
Wider context from the report
“(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG). (2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred. (3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available. (4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment. The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds. ”
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 NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable
Wider context from the report
“(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG). (2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred. (3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available. (4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment. The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds. ”
Open source report
12 Feb2016
Avon
Concerns raised4
1. Lack of a standardised referral process for the ‘hot foot’ clinic
2. Insufficient resources for demand from new and follow-up patients at the ‘hot foot’ clinic
3. Delays in prioritising urgent referrals to the ‘hot foot’ clinic
1. Lack of guidance for referrers on clinic referral and alternative assessment and treatment options
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

Ms. Marilyn Anson · 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. Marilyn Anson had diabetes and end-stage renal failure requiring dialysis, and developed a severe left-foot pressure ulcer. An urgent referral to the ‘hot foot’ clinic was made on 26 February 2015, but the earliest appointment offered was 17 March; the ulcer deteriorated, requiring hospital admission, antibiotics and amputation surgery, and she died after further surgery on 22 March 2015. The concerns included the prioritisation and resourcing of the clinic, coordination between relevant organisations, and guidance and standardisation of referrals.

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 NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a standardised referral process for the ‘hot foot’ clinic
Wider context from the report
“(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
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 NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Insufficient resources for demand from new and follow-up patients at the ‘hot foot’ clinic
Wider context from the report
“(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
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 NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Delays in prioritising urgent referrals to the ‘hot foot’ clinic
Wider context from the report
“(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
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 NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of guidance for referrers on clinic referral and alternative assessment and treatment options
Wider context from the report
“(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment

Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable

Concerns raised4

Lack of a standardised referral process for the ‘hot foot’ clinic

Insufficient resources for demand from new and follow-up patients at the ‘hot foot’ clinic

Delays in prioritising urgent referrals to the ‘hot foot’ clinic

Lack of guidance for referrers on clinic referral and alternative assessment and treatment options