Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents View source See 4 more concerns
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
Katie MADDEN · 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
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of independent Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report
Concerns raised 5 Unavailability of practitioners to answer received calls View source Insufficient practitioner time to gather information and conduct triage and risk assessment View source Lack of thorough risk assessment and safety planning View source Inconsistent judgement of triage scale View source Insufficient professional curiosity around risk and suicidal ideation View source See 2 more concerns
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
Paul Alexander Meadows · 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
Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.
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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of practitioners to answer received calls
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient practitioner time to gather information and conduct triage and risk assessment
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess .
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess . Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of thorough risk assessment and safety planning
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case . There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inconsistent judgement of triage scale
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation.
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional curiosity around risk and suicidal ideation
Wider context from the report “The Norfolk & Suffolk NHS Foundation Trust accepted that there were broad issues in relation to thoroughness of risk assessment and safety planning in other cases as well as Paul’s case. There were inconsistencies in judgement of triage scale and the level of professional curiosity around risk and suicidal ideation .
It was accepted that, in Summer 2021, due to resource pressure – specifically, a discrepancy between the anticipated activity and the actual, significant, volume of callers, there were occasions when First Response Service practitioners did not have enough time to gather the required information and properly to triage and risk assess.
The evidence was that, although the position now varies considerably from day to day, due in particular to difficulties with vacancies it would be unfair to say that staff do not still feel pressured at times on calls.
The evidence was that the difficulties in recruitment are associated with differences in funding for the First Response Service between the commissioners for different counties. For example, there is a significant difference between the funding available to Norfolk and to Suffolk, despite both counties having a similar volume of calls.
The Commissioners are aware of the number of calls unanswered because of practitioners being unable to take the calls received and the matter remains one that is raised with the Commissioners on an ongoing basis and subject to ongoing negotiation.
Nevertheless, the Court has, to recap, received evidence that, given difficulties in recruitment arising out of the level of funding received by the First Response Service in Suffolk, it remains the position that practitioners do not always have sufficient time on calls to gather the required information and properly to triage and risk assess. Where, for these reasons, First Response practitioners are not able properly to triage and risk assess, this creates a risk of future deaths that will occur or will continue to exist in the future.
The evidence was also that this is not just a concern in one county, but one that is experienced nationally.
” Open source report
Concerns raised 6 Lack of emergency department capacity for timely ambulance patient transfer View source Failure to maintain emergency department and inpatient capacity for timely ambulance admissions View source Limited capacity for diagnosis and treatment while patients wait in ambulances View source Insufficient safety checks to reveal the extent of injuries in patients left in ambulances View source Delays in ambulances attending other emergencies View source Reliance on safety checks for patients left in ambulances because of emergency department space delays View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 14
Action
Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023. View source
Action
Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Develop a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023. View source
Action
Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Coordinate the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023. View source
Action
Coordinate local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023. View source
Action
Implement the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Deploy additional ambulance resources across the three acute trusts to cohort suitable patients and release community response capacity.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Deliver the Leading for System Change project to identify and address system-wide discharge barriers.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023. View source
Action
Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2023. View source
Action
Monitor and support completion of the hospital spinal-referral review and clinical-governance learning actions.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2023. View source See 11 more actions
×
AI-generated summary
Kyriacos Athanasis · 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
Kyriacos Athanasis, an 88-year-old man with frailty and several medical conditions, fell down stairs and sustained an unstable cervical spine fracture. Delays transferring him from an ambulance and diagnosing the fracture were followed by pneumonia, and he died after deteriorating. The principal concerns were emergency department overcrowding, insufficient ambulance patient safety checks, delayed diagnosis and treatment, and resulting risks to patients awaiting ambulance transfer or care.
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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency department capacity for timely ambulance patient transfer
Wider context from the report “(1) Evidence given at the inquest revealed that there was a delay in Mr. Athanasis being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into .
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain emergency department and inpatient capacity for timely ambulance admissions
Wider context from the report “(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave . The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances . This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited capacity for diagnosis and treatment while patients wait in ambulances
Wider context from the report “(5) Significant local steps have been taken to reduce the risks to patients, but the department is functioning well over their capacity (at the time of the hearing the Trust had 75 patients in a department designed for 40). There are clear risks of future deaths for patients waiting for an ambulance as well as to patients whose diagnosis and treatment is delayed due to limited intervention being available in the back of an ambulance .
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety checks to reveal the extent of injuries in patients left in ambulances
Wider context from the report “(3) In this instance the mechanism to undertake a safety check was not sufficient to reveal the extent of the injuries Mr. Athanasis had sustained, and this meant there was a delay in diagnosing him with his unstable cervical fracture . This delay in conjunction with other issues more than minimally or trivially contributed to his death.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulances attending other emergencies
Wider context from the report “(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Reliance on safety checks for patients left in ambulances because of emergency department space delays
Wider context from the report “(2) As there had been known delays in obtaining space in the emergency department at the Trust senior clinicians undertook a safety check of those patients left in ambulances to assess the urgency and need for a trolley or bed .
” Open source report
×
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 Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.
Verbatim wording from the response “Since May 2022 the ICB has supported all 3 acute hospitals within our system, including the JPUH, to further develop and expand its GP Streaming Unit which provides a pathway for ED staff to assess patient needs on arrival and ensure that those who are more suitable for GP care can attend the unit co-located within the department. This helps to create flow and promote more prompt clinical assessment.” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.
Verbatim wording from the response “In addition to the above, the ICB has continued to support provider-level actions to increase oversight of patients in waiting ambulances, enabling collaboration between ambulance and hospital providers to put in place new ways of working to maintain patient safety, that transcend traditional organisational responsibilities. For example, this includes a ‘pit-stop’ assessment model that came into effect at JPUH in June 2022, which enables early diagnostics to be commenced for patients before they enter the ED. This initiative was supported by the use of additional temporary staff including the use of reservists, additional bank staff and medical” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.
Verbatim wording from the response “Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.
Verbatim wording from the response “The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and releablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.
Verbatim wording from the response “However, since August 2022 the NHS has released additional money for investment in discharge resources. In the first allocation the Norfolk and Waveney system was awarded £9m revenue and £2m capital, which was invested in new health and social care beds and community packages of care creating the equivalent of approximately 250 beds. In mid-November 2022 the government announced a further £500m fund for health and social care, of which our system share was approximately £11m which is currently being used to commission additional care and support services to further ease the burden on hospital beds. A third award was announced in January 2023 providing a further £3.74m revenue to be spent by 31st March 2023.” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 Coordinate the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.
Verbatim wording from the response “The ICB is coordinating the system Discharge Programme which brings providers together to collaborate on the utilisation of this money; jointly planning, delivering, and monitoring improvement actions, including:” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 Coordinate local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.
Verbatim wording from the response “nationally. We continue to follow the national NHS Operational Pressure Escalation Level Framework to identify, escalate and respond to flow pressures across our system. The ICB continues to coordinate a programme of local improvement, which is built optimising and utilising the funding we have been allocated, to focus on the following local priorities:” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.
Verbatim wording from the response “The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
×
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 Deploy additional ambulance resources across the three acute trusts to cohort suitable patients and release community response capacity.
Verbatim wording from the response “Additionally, in order to effect earlier release of ambulance resources into the community, additional ambulance resources have been utilised across all three Acute Trusts to enable cohorting of suitable patients, thereby releasing ambulance resources. Whilst this does not address directly, ambulance handover times it does improve the safety of patients within the community who would otherwise face longer waits for ambulance attendance. This is supported by established frameworks which identify the scope of clinical practice of the available hospital staff members and is further supported by provider and system level escalation frameworks such as the OPEL and critical incident management framework.” Source location Response from Norfolk and Waveney Integrated Care Board
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 Deliver the Leading for System Change project to identify and address system-wide discharge barriers.
Verbatim wording from the response “The ICB has also placed senior clinical staff in to our three Acute Hospitals for focussed periods of on-site support, to support the management of escalations in a timely manner. Not only does this provide additional operational support to frontline colleagues, utilising ICB staff experience, it also improves ICB oversight and assurance, enabling the ICB to actively reflect on the operational impact that their system-level interventions (as described above) are having on patients and the staff delivering their care. The Norfolk and Waveney ‘Leading for System Change’ project launched in 2022, bringing together key colleagues involved in discharge across the Integrated Care System (ICS) with a focussed remit to understand, mitigate and rectify some of our underlying problems as a system which include:” Source location Response from Norfolk and Waveney Integrated Care Board
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 commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.
Verbatim wording from the response “The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.” Source location Response from Norfolk and Waveney Integrated Care Board
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 Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.
Verbatim wording from the response “The ICB coordinated systemwide adoption in October 2022 of the Professional Standards of Care for Patients Waiting in Ambulances to ensure patients awaiting handover to ED receive consistent, timely and clinically appropriate care, and that processes are in place to rapidly identify and escalate care needs for deteriorating patients. The ICB continues to monitor compliance with these standards, through daily system calls and discussion with site teams, as well as focused on-site quality visits.” Source location Response from Norfolk and Waveney Integrated Care Board
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 Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.
Verbatim wording from the response “The ICB has focussed resources into the expansion of Same Day Emergency Care (SDEC) provision across all acute hospital sites as an alternative to ED attendance. This is an additional service which provides an alternative pathway for patients who require diagnostics and assessment, which can be undertaken without an overnight stay or prolonged hospital attendance.” Source location Response from Norfolk and Waveney Integrated Care Board
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 Monitor and support completion of the hospital spinal-referral review and clinical-governance learning actions.
Verbatim wording from the response “Action 2: Hospital to undertake a review of their spinal referral process and develop a new Standard Operating Procedure to supplement their existing clinical guidelines. Progress: Action to be completed by the end of March 2023. ICB will monitor and provide any support required.” Source location Response from Norfolk and Waveney Integrated Care Board
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 Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.
Verbatim wording from the response “The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and releablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital” Source location Response from Norfolk and Waveney Integrated Care Board
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 Discharge capacity was constrained after national funding ended and the ICB’s temporary local funding extension ceased.
Verbatim wording from the response “Nationally, the NHS stopped the Hospital Discharge Fund on 31 March 2022, which had essentially funded 4 weeks of ‘free care’ to support patient discharge, regardless of who was responsible for commissioning this care and which also paid for a large range of services and beds. This meant that on 1st April the Norfolk and Waveney system lost funding for” Source location Response from Norfolk and Waveney Integrated Care Board
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 The rapid-release protocol can only be mobilised in specific clinical circumstances, limiting its use to reduce ambulance handover delays.
Verbatim wording from the response “The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.” Source location Response from Norfolk and Waveney Integrated Care Board
Open published response
Concerns raised 1 Gap in commissioned service provision for ARMS patients in Norfolk and Waveney View source
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.
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AI-generated summary
Sean Kay · 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
Sean Kay had longstanding mental health problems and was awaiting confirmation of ongoing support when his body was recovered from an area of water near Stonea Bridge on 26 February 2020. The report states that he had taken his own life while the balance of his mind was disturbed. The principal concern was a gap in commissioned service provision in Norfolk and Waveney, leaving him between services without appropriate care.
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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Gap in commissioned service provision for ARMS patients in Norfolk and Waveney
Wider context from the report “The evidence clearly identified a gap in service provision in the Norfolk and Waveney area for the cohort of patients into which Sean fitted .
Although having been identified as ARMS by the EIPT in Norfolk and Waveney, Sean nonetheless did not fit the strict criteria for accessing that service as he was deemed to have not yet suffered a first episode of psychosis; however his level of risk was sufficiently high that he was also considered unsuitable for WBS . Additionally, the evidence confirmed that Sean did not fit the criteria of either the Community Mental Health Team, the Crisis Team or MIND .
In contrast, in the neighbouring Suffolk area (and the evidence suggested in many other areas of the country) ARMS patients are recognised as falling under the commissioned EIPT umbrella and therefore receive commissioned assessment, treatment and management from that team.
This lacunae in service provision in Norfolk and Waveney meant that, at the time of his death, Sean fell between services and did not receive any appropriate care . In my opinion the continuation of such a lacunae in commissioned service provision gives rise to the risk of future deaths .
” Open source report
Concerns raised 3 Failure to organise a multi-disciplinary learning event on emergency non-technical skills View source Failure to maintain up-to-date written care and crisis plans View source Delays in Eating Disorder Service assessment due to caseload capacity View source
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
Tyla Katherine Joan COOK · 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
Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.
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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to organise a multi-disciplinary learning event on emergency non-technical skills
Wider context from the report “3. The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non-technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event . The Care providers indicated it was the West Norfolk Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group Review was published 8 May 2019. No steps have been taken with regard to this learning event , save East of England Ambulance Service Trust has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place .
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date written care and crisis plans
Wider context from the report “2. There was no written up-to-date care and crisis plans in place . The most recent written care plan related to Tyla being an inpatient at the Dragonfly Unit, from where he was discharged on 9 August 2017. The written plans were therefore several months out of date . This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further 3 months was requested to prepare an up to date written care plan. In the event, and despite the family’s repeated requests for plans in writing, it was decided the care plan could be commenced by 30 November 2017, on the basis Tyla’s input into the Care Plan was important and it would take time to gain his meaningful input. The evidence was that there were oral plans in place which were relayed to the parents (including at times of distress), who continued to request plans in writing. The high level of distress and anxiety within Tyla’s home was recognised. An interim written plan was not considered nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken by the Trust to recognise when up to date written plans are not in place and it is understood staff have undergone some work in improving the quality of care plans. However in this case an active decision was made not to update the written plan for some time . Further the evidence did not reveal any insight into the support a written plan could have given the family to support Tyla.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in Eating Disorder Service assessment due to caseload capacity
Wider context from the report “1. It was agreed at the CETR meeting on 9 August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017 . The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla ;
” 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 Arrange the multidisciplinary learning event for mid-February 2020.
Verbatim wording from the response “The actions (with provisional timescales to be confirmed by the group members) agreed at the task and finish group meeting are ongoing and include:” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 Develop learning-event materials covering the incident, organisational changes, staff messages and relevant lessons learned.
Verbatim wording from the response “• The materials to be developed for the learning event are to include a pen portrait of Tyla (his parents are to be invited to share their views on this), changes made by NSFT and QEH in light of the incident and key messages from the staff involved in the incident. Information regarding the relevant Lessons Learnt will also be included e.g. Lesson Learnt 12 - Monitoring of acute physical health deterioration.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 Arrange and chair a multidisciplinary task-and-finish group meeting to develop the learning event.
Verbatim wording from the response “• Arranged for the task and finish group (with attending representatives from NSFT, EEAST, QEH, NCC and West Norfolk CCG) to meet on 04 November 2019 to discuss the development of the learning event. Action completed 04 November 2019.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 Invite senior operational staff from NNUH and James Paget University Hospitals to disseminate incident and investigation learning.
Verbatim wording from the response “• As part of the sharing and dissemination of the outcomes of this incident and the Investigation report, the invitees to the learning event are to include senior operational staff from the Emergency Department at Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) and James Paget University Hospitals NHS Foundation Trust.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 Identify and secure an external facilitator for the proposed learning event.
Verbatim wording from the response “• An External facilitator for the learning event has been identified by West Norfolk CCG and is available for the proposed date of the learning event.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 Request QEH’s Risk and Safety team to compile investigation learning for consideration by the task-and-finish group.
Verbatim wording from the response “• Requested QEH (Risk and Safety team) to draw together the learning from the Investigation Report for consideration by the task and finish group (in line with Action 1 of Recommendation 2). Action completed 01 November 2019.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 QEH and its Deputy Director of Patient Safety are the organisational and individual leads for Recommendation 2 and the learning event.
Verbatim wording from the response “Recommendation 2 clearly states that firstly, the task and finish group is responsible for the implementation of the recommendation (i.e. is the ‘action owner’). Secondly, that QEH and its Deputy Director of Patient Safety are the organisational and individual leads respectively for this recommendation.” Source location 2019-0299-Response-by-West-Norfolk-CCG
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 The CCG did not agree to lead or take over responsibility for Recommendation 2 or the learning event.
Verbatim wording from the response “Accordingly there was no agreement by the CCG at that time or subsequently that the CCG would take the lead on any training event or Recommendation 2.” Source location 2019-0299-Response-by-West-Norfolk-CCG
Open published response
Concerns raised 2 Failure to ensure that correspondence concerning a patient’s suicide risk or self-harming behaviour is noted View source Failure of GP practice guidelines to require referral of correspondence concerning a patient’s suicide risk or self-harming behaviour to a doctor or GP View source
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.
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AI-generated summary
DARREN LEE ARNOUP · 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
Darren Arnoup was found hanging in the garage of his home on 27 October 2013 and was declared deceased at the scene. The report raises concern that correspondence containing information about a patient's suicide risk or self-harming behaviour might not be brought to a GP's attention, because it may be treated as information-only correspondence and filed without medical review.
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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that correspondence concerning a patient’s suicide risk or self-harming behaviour is noted
Wider context from the report “In the light of that evidence I am concerned that there is a continuing risk that letters containing information about a concern for the suicide risk or self-harming behaviour of a patient will not be noted . Whilst it is not known whether in the case before me had the GP noted the content of the letter the tragic outcome would have been different I can readily envisage situations where it could.
I am therefore concerned that guidelines operated by GP practices/surgeries, including the Mundesley Medical Centre may need to be reviewed to ensure that in future correspondence which refers to a concern for the suicide risk or self-harming behaviour of a patient is required to a Doctor/GP so that the Doctor/GP is aware of the concern.
” 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 Norfolk and Suffolk Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of GP practice guidelines to require referral of correspondence concerning a patient’s suicide risk or self-harming behaviour to a doctor or GP
Wider context from the report “In the light of that evidence I am concerned that there is a continuing risk that letters containing information about a concern for the suicide risk or self-harming behaviour of a patient will not be noted. Whilst it is not known whether in the case before me had the GP noted the content of the letter the tragic outcome would have been different I can readily envisage situations where it could.
I am therefore concerned that guidelines operated by GP practices/surgeries, including the Mundesley Medical Centre may need to be reviewed to ensure that in future correspondence which refers to a concern for the suicide risk or self-harming behaviour of a patient is required to a Doctor/GP so that the Doctor/GP is aware of the concern .
” Open source report
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Request correction
Addressed to NHS Norfolk and Waveney Integrated Care Board, now represented here by NHS Norfolk and Suffolk Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations