23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Update the AWOL Policy with a clear risk-escalation process map, then share it with staff and add it to the section 17 competency framework.
Verbatim wording from the response “This Inquest has highlighted that not all staff are aware that the above risk escalation process should be followed in the event that a person is AWOL and needs to be returned to the ward. We take full responsibility and we will therefore update our AWOL Policy with a clear process map that outlines how concerns about a person who is AWOL should be escalated by September 2019. Thereafter, this will be shared with staff and added to the section 17 competency framework to ensure awareness of the process.” Source location Sasha-Forster-R2019-01693
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 Continue providing local-induction training so staff understand the AWOL policy and the process to follow when a person is absent without leave.
Verbatim wording from the response “I hope that the above reassures you that there is a process in place to facilitate the return of AWOL inpatients to the ward and that the Trust is committed on an ongoing basis to provide training through local induction to our staff and ensuring they are aware of the policy and process they should follow when a person is AWOL.” Source location Sasha-Forster-R2019-01693
Open published response
×
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 Existing risk assessment, staffing allocation and escalation arrangements are considered sufficient to return known AWOL patients safely.
Verbatim wording from the response “known, and they are not posing a risk to themselves or others, we agree that it is the Trust’s responsibility to arrange for them to be returned to the ward by SABP staff; in line with our Absent Without Leave Missing Persons Policy. Staff have access to the hospital pool car, taxi services, or secure / NHS ambulance transport in order to facilitate the return of a person who is AWOL to the ward, depending on what is considered to be most appropriate in the circumstances, following a risk assessment.” Source location Sasha-Forster-R2019-01693
Open published response
×
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 Maintaining additional staffing on every ward for AWOL returns is considered impractical because such incidents are uncommon and wards meet safe staffing standards.
Verbatim wording from the response “It would be impractical for SABP to have extra staffing on each ward on a shift by shift basis for the purpose of being available to return people who are AWOL and whose whereabouts are known, particularly as this is an uncommon occurrence. All our Wards comply with National Safe Staffing standards.” Source location Sasha-Forster-R2019-01693
Open published response
24 Mar 2014 Phyllis Barnes · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery View source Failure of visiting general practitioners to appreciate the seriousness of patients’ conditions View source Lack of formal communication opportunities for patients’ relatives to report patients’ conditions to primary care clinicians View source Unreliable promised telephone follow-up View source See 1 more concern
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
Phyllis Barnes · 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
Phyllis Barnes underwent elective laparoscopic anterior resection and was discharged home, but developed persistent vomiting and became increasingly unwell. She was later readmitted with an anastomotic leak and died from complications. Concerns included delayed recognition of the seriousness of her symptoms, a superficial nurse-led telephone consultation with uncertain follow-up, and a lack of formal communication with her daughter.
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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery
Wider context from the report “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
” 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure of visiting general practitioners to appreciate the seriousness of patients’ conditions
Wider context from the report “1. Failure of visiting General Practitioner to appreciate the seriousness of Mrs Barnes condition in view of her recent operation and persistent symptoms
” 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 North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Lack of formal communication opportunities for patients’ relatives to report patients’ conditions to primary care clinicians
Wider context from the report “3. There was no formal communication or opportunity for Mrs Barnes’s daughter to relate her mother’s condition to the GP or the Nurse Practitioner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS North East Hampshire and Farnham Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Unreliable promised telephone follow-up
Wider context from the report “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations