Recipient

NHS Somerset Integrated Care Board

First report 4 Oct 2017•Latest report 4 Oct 2017

Recipient record

Reports, concerns and published responses

Health and care · Integrated care board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from NHS Somerset Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

4 Oct2017
Somerset
Concerns raised6
1. Delays in access to CBT
2. Failure to urgently contact the school about the need for psychiatric input
3. Insufficient detail in care plans to record safeguarding requirements
1. Failure to obtain urgent psychiatric input
2. Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change
3. High threshold for CAMHS referral
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

Sofia Ann Legg · 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

Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI Report.

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 Somerset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Delays in access to CBT
Wider context from the report
“2. Availability of CBT. Sofia was placed on a 6 month waiting list for CBT. This delay appears considerable. ”
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 Somerset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to urgently contact the school about the need for psychiatric input
Wider context from the report
“4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia. ”
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 Somerset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Insufficient detail in care plans to record safeguarding requirements
Wider context from the report
“4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia. ”
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 Somerset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain urgent psychiatric input
Wider context from the report
“3. Sofia’s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance. ”
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 Somerset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change
Wider context from the report
“5. Language used in the SIRI Report was felt to be inappropriate. The SIRI Report effectively said if the care plan had been followed the outcome might have been different and that no change in clinical practice would have resulted in any different outcome. I do not believe either of these statements were true. ”
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 Somerset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
High threshold for CAMHS referral
Wider context from the report
“1. Access to CAMHS. Sofia was rejected for referral in April 2015. Might a lower threshold and earlier proactive interventionist policy has been of positive benefits to Sofia. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised6

Delays in access to CBT

Failure to urgently contact the school about the need for psychiatric input

Insufficient detail in care plans to record safeguarding requirements

Failure to obtain urgent psychiatric input

Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change

High threshold for CAMHS referral