NHS Herefordshire and Worcestershire Talking TherapiesIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 24 Oct 2022•Latest report 24 Oct 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from NHS Herefordshire and Worcestershire Talking Therapies linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████, Clinical Lead, Herefordshire and Worcestershire Healthy Minds.

    Herefordshire

    AI-generated summary

    Terri Ann Malone · 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

    Terri Ann Malone was drinking excessively and probably died from ketoacidosis as a consequence of excessive alcohol consumption. The concerns included treatment planning without direct contact by an experienced practitioner, discharge after a missed appointment and unanswered voicemail despite a lengthy wait, and discharge without establishing her current circumstances or other agencies’ involvement.

    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 Herefordshire and Worcestershire Talking Therapies; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish current circumstances and input from other agencies before discharge

    Wider context from the report

    “(3) A decision is made to discharge the patient without establishing their current circumstances and the current (if any) input from other agencies; full details of whom and consent to share information could be obtained during initial instructions taken by a more experience practitioner. ”
    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 Herefordshire and Worcestershire Talking Therapies; that does not assign responsibility.

    PFD Monitor interpretation

    Discharge of service users after missed appointments without adequate follow-up

    Wider context from the report

    “(2) Notwithstanding the above a service user is discharged from the service if they fail to attend an appointment and do not respond to a voicemail by the end of the day. This despite the patient being required to wait several months for an appointment. ”
    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 Herefordshire and Worcestershire Talking Therapies; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to involve an experienced practitioner directly in treatment-plan decisions

    Wider context from the report

    “(1) Initial contact with the service is with an inexperienced practitioner and a decision is made regarding a treatment plan without any direct contact being made by an experienced practitioner. ”
    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

Data last updated 7 September 2026