NHS Somerset Integrated Care Board

Health and care · Integrated care board

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First report 4 Oct 2017•Latest report 4 Oct 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Somerset

    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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026