NHS Lothian

Health and care · Local health board

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First report 8 Sep 2017•Latest report 8 Sep 2017

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
2

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 Lothian linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Black Country

    AI-generated summary

    Melvin James and Anne-Marie James · 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

    Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.

    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 Lothian; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to incorporate relevant information into discharge assessment

    Wider context from the report

    “1. Evidence emerged during the inquest that by the time of his discharge on Friday 10th February 2017 and as far as the Hospital were concerned, they recorded he showed no evidence of mental illness. However, the Clinician who dealt with the discharge confirmed that he wasn’t aware of the conversation he had with his brother on the way to Wolverhampton where Mr James was still talking about his delusions including creatures transforming. Significantly, during the inquest he accepted, had he known this he would have formed the view that he was still unwell. ”
    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 Lothian; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate relapse warning signs to family

    Wider context from the report

    “2. He also accepted that there was a missed opportunity in communication and information sharing and it was regrettable they didn’t speak to the family and explain what symptoms to look out for in case of relapse. ”
    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 Lothian; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make formal post-discharge referral or contact with community mental health services and general practitioner

    Wider context from the report

    “3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area. There was no evidence of any aftercare being delivered after discharge back into the community. ”
    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 Lothian; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of post-discharge community aftercare

    Wider context from the report

    “3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area. There was no evidence of any aftercare being delivered after discharge back into the community. ”
    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