15 Apr 2014 Mr Philip Anthony Dean · Prevention of Future Deaths report Inner West London
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Concerns raised 6 Insufficient HHT funding for continuity of care and named designated workers View source Failure of the SUI report to identify all matters in issue View source Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section View source Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel View source Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians View source Discharge-dependent referral to psychology leaving patients without ongoing support View source See 3 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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× 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations