Recipient

NHS Wandsworth Clinical Commissioning Group

First report 15 Apr 2014•Latest report 15 Apr 2014

Recipient record

Reports, concerns and published responses

Health and care · Clinical commissioning group. 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 Wandsworth Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Apr2014
Inner West London
Concerns raised6
1. Insufficient HHT funding for continuity of care and named designated workers
2. Failure of the SUI report to identify all matters in issue
3. Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section
1. Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel
2. Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians
3. Discharge-dependent referral to psychology leaving patients without ongoing support
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

Mr Philip Anthony Dean · 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

Mr Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

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 Wandsworth Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Insufficient HHT funding for continuity of care and named designated workers
Wider context from the report
“(1) That the HHT is not sufficiently funded to allow continuity of care and named designated workers. ”
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 Wandsworth Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure of the SUI report to identify all matters in issue
Wider context from the report
“(6) That The SUI report missed all matters in issue in this case. ”
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 Wandsworth Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section
Wider context from the report
“(4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best. ”
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 Wandsworth Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel
Wider context from the report
“(5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel, and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients. ”
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 Wandsworth Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians
Wider context from the report
“(3) That liaison psychiatry does not record pertinent information such as GP recommends section, thus denying those coming after the benefit of the GP’s professional opinion. ”
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 Wandsworth Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Discharge-dependent referral to psychology leaving patients without ongoing support
Wider context from the report
“(2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim. ”
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

Insufficient HHT funding for continuity of care and named designated workers

Failure of the SUI report to identify all matters in issue

Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section

Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel

Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians

Discharge-dependent referral to psychology leaving patients without ongoing support