17 Feb 2025 Joshua Jay Weavers · Prevention of Future Deaths report Hertfordshire
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Concerns raised 4 Failure to implement planned reforms to ASD assessments View source Failure of bridge safety measures to meet current guidance for preventing pedestrian jumping or falling View source Delays in ASD assessments View source Lengthy waiting times for ASD assessments in Hertfordshire View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Joshua Jay Weavers · 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
Joshua Jay Weavers died on 4 March 2021 after jumping from a railway bridge and being struck by a high-speed train. The report raises concerns about lengthy waits for autism spectrum disorder assessments, delays in implementing assessment-service reforms, and bridge safety measures that did not meet current guidance.
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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to implement planned reforms to ASD assessments
Wider context from the report “2. That whilst the local mental health Trust has plans to reform the manner in which ASD assessments for patients under their care are undertaken, the implementation of those plans awaits input from the Integrated Care Board . This means that waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a risk of future deaths occurring for the reasons set out above.
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of bridge safety measures to meet current guidance for preventing pedestrian jumping or falling
Wider context from the report “3. That the safety measures in place on the ████████ to guard against pedestrians either jumping or falling from the bridge do not meet current guidance , and therefore gives rise to a risk of future deaths occurring.
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in ASD assessments
Wider context from the report “1. That, nationally, waiting times for ASD assessments are very long . Such assessments are important in guiding effective care and treatment, as well as being a potential gateway to access other relevant services. This combined with the fact of an increased risk of suicidal behaviour amongst those who receive a diagnosis of ASD, gives rise to a concern that future deaths may occur on account of the delays in ASD assessment .
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lengthy waiting times for ASD assessments in Hertfordshire
Wider context from the report “2. That whilst the local mental health Trust has plans to reform the manner in which ASD assessments for patients under their care are undertaken, the implementation of those plans awaits input from the Integrated Care Board. This means that waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a risk of future deaths occurring for the reasons set out above.
” 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 Develop a care coordinator role to support families through the clinical pathway and keep them informed of progress.
Verbatim wording from the response “There are different elements of an ASD assessment, and our new model establishes the resources required to operationalise this activity, specifically:” Source location Response from Hertfordshire and West Essex ICB
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 additional funding and baseline future provider funding to support development of the neurodiversity assessment model.
Verbatim wording from the response “We are working intensively on these issues to support our providers to deliver safe and timely care, including significant investment in pathways. We have provided additional funding for the work listed above for financial years 2023/24 at circa £3 million and 2024/25 at approximately £4.1 million, further funding of £4.3 million is baselined into providers budgets for coming financial years from 2025/26 to continue to support the development of the model previously mentioned. However, it must be acknowledged that despite all the efforts detailed above it is expected that long waits for assessment will remain without wider national support, given the ongoing rises in demand that are persisting.” Source location Response from Hertfordshire and West Essex ICB
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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 pre- and post-diagnosis support for children, young people and families.
Verbatim wording from the response “Work has commenced in a measured and stepped way across our service providers. Key elements include:” Source location Response from Hertfordshire and West Essex ICB
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 Implement a standardised and consistent referral and triage process.
Verbatim wording from the response “Work has commenced in a measured and stepped way across our service providers. Key elements include:” Source location Response from Hertfordshire and West Essex ICB
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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 Develop a new referral front door to improve referral quality, information collation, follow-up and data collection.
Verbatim wording from the response “There are different elements of an ASD assessment, and our new model establishes the resources required to operationalise this activity, specifically:” Source location Response from Hertfordshire and West Essex ICB
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 and develop the Neurodiversity Support Hub and support offer for families and children regardless of diagnosis status.
Verbatim wording from the response “There are different elements of an ASD assessment, and our new model establishes the resources required to operationalise this activity, specifically:” Source location Response from Hertfordshire and West Essex ICB
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 Use pathways involving a wider range of clinical and non-clinical staff specialisms to support diagnosis.
Verbatim wording from the response “Work has commenced in a measured and stepped way across our service providers. Key elements include:” Source location Response from Hertfordshire and West Essex ICB
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 Establish a combined clinical triage and assessment pathway across NHS provider trusts to optimise clinical resources.
Verbatim wording from the response “There are different elements of an ASD assessment, and our new model establishes the resources required to operationalise this activity, specifically:” Source location Response from Hertfordshire and West Essex ICB
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 Long ASD assessment waits are expected to remain without wider national support because demand continues to rise.
Verbatim wording from the response “We are working intensively on these issues to support our providers to deliver safe and timely care, including significant investment in pathways. We have provided additional funding for the work listed above for financial years 2023/24 at circa £3 million and 2024/25 at approximately £4.1 million, further funding of £4.3 million is baselined into providers budgets for coming financial years from 2025/26 to continue to support the development of the model previously mentioned. However, it must be acknowledged that despite all the efforts detailed above it is expected that long waits for assessment will remain without wider national support, given the ongoing rises in demand that are persisting.” Source location Response from Hertfordshire and West Essex ICB
Open published response
15 Jul 2024 Megan Davison · Prevention of Future Deaths report Hertfordshire
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Concerns raised 5 Failure of shared clinical records systems to include private providers View source Lack of integrated healthcare system for diabetes and eating disorders View source Incomplete treatment pathway for DKA View source Lack of treatment pathway for T1DE View source Lack of formal diagnosis for T1DE View source See 2 more concerns
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
Megan Davison · 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
Megan Davison was found deceased at home on 4 August 2017 after hanging herself with the intention of ending her life. The report identified concerns about her discharge from mental health care, limited integration between physical and mental healthcare, the absence of recognised diagnosis and care pathways for Type 1 Diabetes with Disordered Eating and Diabetic Ketoacidosis, and incomplete information-sharing between healthcare providers.
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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of shared clinical records systems to include private providers
Wider context from the report “(c) Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison's death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers , such as The Priory. The perception of healthcare providers such The Priory as "private" providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths.
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of integrated healthcare system for diabetes and eating disorders
Wider context from the report “(b) At a local level in East and North Hertfordshire there is no integrated healthcare system for patients with diabetes and eating disorders as there is in the west of the county.
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Incomplete treatment pathway for DKA
Wider context from the report “(a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA) , an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA . I heard independent evidence from ████████, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that "the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of ████████'s independent expert reports for the Inquest are attached).
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of treatment pathway for T1DE
Wider context from the report “(a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA. I heard independent evidence from ████████, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that "the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of ████████'s independent expert reports for the Inquest are attached).
” 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 Hertfordshire and West Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of formal diagnosis for T1DE
Wider context from the report “(a) On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with T1DE. Specifically, there is no formal diagnosis for T1DE , no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA. I heard independent evidence from ████████, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neurosciences at Kings College London that "the lack of a diagnosis for T1DE has an impact because if you don’t know what you are looking for and there aren’t any criteria that you can screen by then it’s very difficult for both patients and clinicians to understand what is wrong with them and this has hampered development of recognition and treatment pathways and building the research evidence". (Copies of ████████'s independent expert reports for the Inquest are attached).
” 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 Work with regional partners to learn from national pilots and trial integrated T1DE pathways locally.
Verbatim wording from the response “The ICB is working closely with NHS England’s regional mental health and transformation team, to learn from recent national pilots to trial pathways for T1DE patients and apply this within the Integrated Care System (ICS). The regional team have confirmed they are happy to work with the ICB to ensure any learning from the pilots, as well as relevant national guidance, can be incorporated into our local model. Locally, Mental Health commissioners lead an implementation group with membership from all ICB partners including primary care, community commissioning, regional teams, the voluntary sector, service users, and carers to support quality improvement and delivery of eating disorder services and physical health checks. This work will inform further pathway development and improve access to physical health services for people with serious mental health conditions.” Source location Response from Hertfordshire and West Essex ICB
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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 Reinforce ICB case-discussion support and establish a clearer provider escalation process, with access details due by November 2024.
Verbatim wording from the response “Where necessary, the ICB (via its clinical teams) can help to organise case-based discussions. We are reinforcing the availability of this support and ensuring there is a clearer process for local providers to escalate cases to the ICB. If a patient is assessed as needing joint input from diabetes and mental health services, the ICB can convene a case conference as appropriate, with the relevant teams to develop an agreed management plan. Details on how local providers can access this process will be in place by November 2024, enabling clinicians to make best use of this support.” Source location Response from Hertfordshire and West Essex ICB
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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 Develop an integrated diabetic-care model covering complex cases, multidisciplinary case management and mental-health support.
Verbatim wording from the response “To address variation in service provision within different parts of the ICS, the ICB is working with local providers to develop a new, integrated model of diabetic care reflecting the needs of all diabetic patients. This includes the management of complex cases involving multi-disciplinary case management, including mental health support.” Source location Response from Hertfordshire and West Essex ICB
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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 Lead a multi-partner implementation group to improve eating-disorder services and physical-health checks.
Verbatim wording from the response “The ICB is working closely with NHS England’s regional mental health and transformation team, to learn from recent national pilots to trial pathways for T1DE patients and apply this within the Integrated Care System (ICS). The regional team have confirmed they are happy to work with the ICB to ensure any learning from the pilots, as well as relevant national guidance, can be incorporated into our local model. Locally, Mental Health commissioners lead an implementation group with membership from all ICB partners including primary care, community commissioning, regional teams, the voluntary sector, service users, and carers to support quality improvement and delivery of eating disorder services and physical health checks. This work will inform further pathway development and improve access to physical health services for people with serious mental health conditions.” Source location Response from Hertfordshire and West Essex ICB
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 Maintain a shared care record containing data from connected organisations, including some private providers.
Verbatim wording from the response “Within the current phase of work, the ICB now has a shared care record with a rich volume of data being shared from a number of organisations connected; this does include some private providers such as local hospices.” Source location Response from Hertfordshire and West Essex ICB
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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 working with local providers to share patient information appropriately on a case-by-case basis.
Verbatim wording from the response “In the meantime, we continue to work with local providers to ensure that patient information relating to their care is shared appropriately on a case-by-case basis.” Source location Response from Hertfordshire and West Essex ICB
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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 The national T1DE system concern is referred to the Secretary of State for Health, so no further local response is provided.
Verbatim wording from the response “1. On a national level there is not a system which is capable of being operated in a way which will ensure proper integrated healthcare for patients with Type 1 Diabetes with Disordered Eating (T1DE). Specifically, there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis.” Source location Response from Hertfordshire and West Essex ICB
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further shared-record rollout to private and other providers is constrained by technical integration costs, reduced national funding and unresolved future funding.
Verbatim wording from the response “Within Hertfordshire and West Essex Integrated Care System our ambition is to give access to any appropriate person providing care. However, a phased approach to implementation is required to manage this safely as well as due to the significant costs involved. To provide access to the shared care record requires a connection to each care providers system which involves technical integration, information governance process and ongoing revenue funding for that connection.” Source location Response from Hertfordshire and West Essex ICB
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations