18 May 2026 Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report Suffolk
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Concerns raised 3 Failure to identify a dedicated, named care co-ordinator for mental health patients during prolonged planned leave View source Lack of a documented system for highlighting and managing planned, prolonged key care co-ordinator absence View source Failure to ensure coverage of named key care co-ordinators’ roles and responsibilities during planned leave View source
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AI-generated summary
Rebecca Jessie Mclellan (known as Becca) · 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
Becca was found hanging in her flat on 20 November 2023 after police forced entry following concerns raised by a colleague; the postmortem concluded that her death was due to hanging, and the inquest concluded suicide. The report identified an ongoing risk arising from the lack of a dedicated, named care co-ordinator during prolonged planned leave, including a period of approximately nine weeks before Becca’s death.
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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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a dedicated, named care co-ordinator for mental health patients during prolonged planned leave
Wider context from the report “There is no documented system that I consider adequately highlights and manages planned, prolonged key care co-ordinator absence in the Youth team, nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave. There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave .
I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented system for highlighting and managing planned, prolonged key care co-ordinator absence
Wider context from the report “There is no documented system that I consider adequately highlights and manages planned, prolonged key care co-ordinator absence in the Youth team , nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave. There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave.
I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure coverage of named key care co-ordinators’ roles and responsibilities during planned leave
Wider context from the report “There is no documented system that I consider adequately highlights and manages planned, prolonged key care co-ordinator absence in the Youth team, nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave . There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave.
I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.
” Open source report
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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 Implement and apply ratified guidance for managing planned prolonged Youth Team care-coordinator absence, including handover, patient review, reallocation decisions, notification and joint transition appointments.
Verbatim wording from the response “As explained in the attached letter to you dated 13 May 2026 (enclosed), there are specific processes in place both for planned and unplanned leave. I note your concern set out in the prevention of future deaths report, specifically relates to the management of planned and prolonged absence of care-co-ordinators in the Youth Team however.” Source location Response from Norfolk and Suffolk NHS Foundation Trust (2)
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing planned-absence processes and ratified guidance are considered sufficient to document and manage prolonged Youth Team care-coordinator leave.
Verbatim wording from the response “As explained in the attached letter to you dated 13 May 2026 (enclosed), there are specific processes in place both for planned and unplanned leave. I note your concern set out in the prevention of future deaths report, specifically relates to the management of planned and prolonged absence of care-co-ordinators in the Youth Team however.” Source location Response from Norfolk and Suffolk NHS Foundation Trust (2)
Open published response
26 Nov 2024 Amy Jade BUTCHER · Prevention of Future Deaths report Suffolk
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Concerns raised 4 Lack of clinical knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing View source Lack of a clear prescribing decision-making and coordination system for mental health medication View source Unavailability of out-of-hours prescribing of Lorazepam when clinically required View source Failure to make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amy Jade BUTCHER · 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
Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.
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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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing
Wider context from the report “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed.
There were two reasons given for the MDT decision.
Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once.
The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy.
Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made.
In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help.
As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse.
However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects.
In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam.
As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients , a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used , and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective, prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear prescribing decision-making and coordination system for mental health medication
Wider context from the report “Evidence heard at inquest identified a muddled and unclear system for the prescription of medication to someone in Amy’s situation.
The Emergency Department Consultant who saw Amy in crisis on the 10ᵗʰ May 2024 stated that for patients like Amy she had previously prescribed Lorazepam upon discharge home, but could only do this if the Mental Health Team in the ED requested her to do so, which they did not do on this occasion.
The following day, Amy herself tried to obtain a prescription of Lorazepam by dialling NHS 111 Option 2 (Mental Health line). She spoke to a mental health practitioner who told her that NHS 111 Option 2 did not have the ability to prescribe medication, and she would need to call NHS 111 Option 1 and speak to an Out of Hours GP instead.
Amy contacted NHS 111 Option 1 and spoke to an Out of Hours GP, who worked for a private company which had implemented a ban on the prescription of Lorazepam due to its highly addictive properties.
As such, even if the GP had considered Lorazepam to be required in Amy’s case, he could not have prescribed it. The GP prescribed different PRN medications, which were subsequently found in Amy’s system after her death.
Amy’s own GP gave evidence stating that the system for prescribing mental health medication was confusing . He stated that mental health medications prescribed to a patient by a GP (such as antidepressants) before a Mental Health Team became involved, remained the responsibility of the GP.
However, once a Mental Health Team became involved, any changes to the medication regime could only be made by the Mental Health Team.
In addition, some medication would be prescribed by the Mental Health Team directly, whilst other would be prescribed separately by the GP .
The GP described the situation as one of there simply being ‘too many chiefs’.
The net effect of the current system in place is that an individual in Amy’s situation finds themselves needing to make multiple telephone calls or contacts with NHS 111 Option 1, NHS 111 Option 2, their Out of Hours GP Service, their own GP and their Mental Health Team, in order to try and obtain either a new prescription or change their current prescription if their mental health suddenly deteriorates.
There is evidently no single point of contact, or single decision maker regarding prescriptions in these cases .
The evidence suggests that the situation is exacerbated even further if the individual’s mental health deterioration occurs Out of Hours.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours prescribing of Lorazepam when clinically required
Wider context from the report “Evidence heard at inquest identified a muddled and unclear system for the prescription of medication to someone in Amy’s situation.
The Emergency Department Consultant who saw Amy in crisis on the 10ᵗʰ May 2024 stated that for patients like Amy she had previously prescribed Lorazepam upon discharge home, but could only do this if the Mental Health Team in the ED requested her to do so, which they did not do on this occasion.
The following day, Amy herself tried to obtain a prescription of Lorazepam by dialling NHS 111 Option 2 (Mental Health line). She spoke to a mental health practitioner who told her that NHS 111 Option 2 did not have the ability to prescribe medication, and she would need to call NHS 111 Option 1 and speak to an Out of Hours GP instead.
Amy contacted NHS 111 Option 1 and spoke to an Out of Hours GP, who worked for a private company which had implemented a ban on the prescription of Lorazepam due to its highly addictive properties.
As such, even if the GP had considered Lorazepam to be required in Amy’s case, he could not have prescribed it . The GP prescribed different PRN medications, which were subsequently found in Amy’s system after her death.
Amy’s own GP gave evidence stating that the system for prescribing mental health medication was confusing. He stated that mental health medications prescribed to a patient by a GP (such as antidepressants) before a Mental Health Team became involved, remained the responsibility of the GP.
However, once a Mental Health Team became involved, any changes to the medication regime could only be made by the Mental Health Team.
In addition, some medication would be prescribed by the Mental Health Team directly, whilst other would be prescribed separately by the GP.
The GP described the situation as one of there simply being ‘too many chiefs’.
The net effect of the current system in place is that an individual in Amy’s situation finds themselves needing to make multiple telephone calls or contacts with NHS 111 Option 1, NHS 111 Option 2, their Out of Hours GP Service, their own GP and their Mental Health Team, in order to try and obtain either a new prescription or change their current prescription if their mental health suddenly deteriorates.
There is evidently no single point of contact, or single decision maker regarding prescriptions in these cases.
The evidence suggests that the situation is exacerbated even further if the individual’s mental health deterioration occurs Out of Hours .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective
Wider context from the report “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed.
There were two reasons given for the MDT decision.
Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once.
The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy.
Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made.
In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help.
As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse.
However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects.
In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam.
As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients, a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used, and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective , prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy.
” Open source report
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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 monitoring developments concerning benzodiazepine prescribing and emerging evidence for implementation in accordance with future NICE or regulatory guidance.
Verbatim wording from the response “Our clinicians will adhere to their professional codes, national and regulatory guidance in conjunction with the Trust’s Management of Medication Policy.” Source location Response from Norfolk and Suffolk NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add prescribing responsibilities and communication instructions to standard letters sent to GPs when service users join CRHT caseloads.
Verbatim wording from the response “To simplify the position, we have added the following information to our standard letters which are sent to GPs when service users are taken onto CRHT caseloads:” Source location Response from Norfolk and Suffolk NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a joint clinical audit with primary care colleagues three months after implementing the revised CRHT wording and report results to the Trust-wide Safety Group.
Verbatim wording from the response “By way of assurance, the clinical audit team will undertake a joint audit with primary care colleagues 3 months post implementation of the above wording being introduced, the results of which will be reported to our Trust wide Safety Group for consideration.” Source location Response from Norfolk and Suffolk NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to liaise directly with GPs when requesting adjustments to medications already prescribed by GPs.
Verbatim wording from the response “Staff have been reminded of the need to liaise directly with GPs with any requests to adjust medications already prescribed by GPs in the circumstances described above.” Source location Response from Norfolk and Suffolk NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning NHS 111 Option 1 and out-of-hours GP services is outside the respondent’s responsibility.
Verbatim wording from the response “I recognise that Amy interacted with multiple prescribing pathways within the NHS system and whilst NSFT is not the responsible commissioner for NHS 111 Option 1, GP surgeries out of hours GP services we have raised the issue with our Integrated Commissioning Boards with a view to identifying any possible improvements that can be made as a result of the concern raised.” Source location Response from Norfolk and Suffolk NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extremely limited evidence and absent specific guidance constrain development of advice on Lorazepam use alongside microdosed hallucinogenic mushrooms.
Verbatim wording from the response “Our Chief Pharmacist office has advised that the British National Formulary does not, as a standard, list illegal substances as contra-indications.” Source location Response from Norfolk and Suffolk NHS
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9 Oct 2024 Nigel Hutton HAMMOND · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team View source
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.
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AI-generated summary
Nigel Hutton HAMMOND · 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
Nigel Hammond died at Addenbrooke’s Hospital on 14 March 2024, three days after falling from a window at home and sustaining serious injuries. The inquest concluded that the death was suicide while the balance of his mind was disturbed. The principal concern was that the AMHP could not directly refer Nigel to the Crisis Resolution and Home Treatment Team, and that this may have delayed support before his fatal fall.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team
Wider context from the report “7. That said, although Nigel did not meet the criteria for immediate admission, the AMHP believed Nigel was mentally very unwell, and in need of immediate support. The court heard that such support would be available within a 4-hour target time, from the emergency Crisis Resolution and Home Treatment Team.
8. However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team .
9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11th March 2024 . Nigel’s fall which led to his death, occurred at 06:25 that morning.
10. I am concerned, as had the AMHP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended , and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death.
” Open source report
15 Jul 2024 Owen Donald GARDNER · Prevention of Future Deaths report Suffolk
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Concerns raised 2 Failure to consistently inform agreed next-of-kin contacts of appointments View source Lack of a system for notifying chosen contacts of short-notice appointment changes View source
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Each statement is shown once, even when linked to more than one concern.
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Owen Donald GARDNER · 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
Owen Donald GARDNER, aged 29, died following a road traffic collision; the medical cause of death was recorded as multiple injuries. The report raises concern that agreed next-of-kin contacts were not consistently informed about appointments or short-notice changes, contributing to missed appointments for a person with limited short-term memory and cognitive deficit, and that no system was in place to facilitate this.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently inform agreed next-of-kin contacts of appointments
Wider context from the report “In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered.
As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care.
Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion.
In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact.
This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend.
It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome.
However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment.
Evidence was heard that there is no system in place to facilitate this.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for notifying chosen contacts of short-notice appointment changes
Wider context from the report “In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered.
As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care.
Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion.
In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact.
This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend.
It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome.
However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment.
Evidence was heard that there is no system in place to facilitate this .
” Open source report
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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 Ensure future assessments consider short-term memory difficulties and record communication preferences in combined assessments, recovery plans and safety plans.
Verbatim wording from the response “The outcome from this meeting was that the EPR system enhancement noted at paragraph 2 will be helpful and the team, mutually ensure that all future assessments will include consideration of possible short term memory difficulties and confirmation of communication preferences which will be recorded in the combined assessment/recovery plan and safety plans.” Source location Response from Norfolk and Suffolk NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and assess a Lorenzo enhancement for sending appointment correspondence to nominated next of kin or carers according to patient preference.
Verbatim wording from the response “2. In the interim the trust has commenced work on enhancing the current EPR, Lorenzo. We have identified a potential enhancement that will allow staff to indicate, when generating correspondence (including appointments) that the correspondence should also be sent to the Next of Kin or Carer, according to stated patient preference.” Source location Response from Norfolk and Suffolk NHS
Open published response
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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 community services standard operating procedure with Lorenzo guidance and expectations for recording communication preferences in care documentation.
Verbatim wording from the response “4. In addition, our community services standard operating procedure will be updated to include the guidance on the enhanced changes to Lorenzo, along with confirmation of the expectation that communication preferences will be noted in the service user care plan/combined assessment for ease of reference when communicating with service users and those supporting them.” Source location Response from Norfolk and Suffolk NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the Think Carer and Family programme to improve consistent recording of carers and next of kin, including Trust-wide rollout from October 2025.
Verbatim wording from the response “5. The Trust had also initiated a Listening into Action™ pioneer programme called Think Carer and Family. The Listening into Action™ programme approach is a comprehensive, systemic, outcome-oriented approach to empower staff at all levels to work through any challenges to ensure quality outcomes. In order to bring greater consistency to recording next of kin details to ensure that the technical improvement and system expectation mentioned in the above paragraphs can be meaningfully applied, the aim of the Think Carer and Family LiA programme which was launched on 10 June 2024 is to have 90% of carers and 100% of Next of Kin documented on service users’ records. Initially within Child and Adolescent Mental Health Team, West Suffolk, and Adult Crisis and Resolution Home Treatment Team, West Suffolk, rolling out to the rest of the trust from October 2025.” Source location Response from Norfolk and Suffolk NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a patient safety alert keeping communication with next of kin and carers a primary staff focus during system changes.
Verbatim wording from the response “3. The Trust has also issued a patient safety alert to ensure the process remains a primary focus for our staff while this work is completed. This is attached for information.” Source location Response from Norfolk and Suffolk NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The new electronic patient record is delayed because procurement must follow the nationally mandated purchasing route.
Verbatim wording from the response “1. The Trust is in the process of procuring a new Electronic Patient Record (EPR) which includes ‘patient portal’ functionality that will enhance our capabilities for appointment scheduling, particularly in terms of visibility for patients. This new EPR is approximately two years from being” Source location Response from Norfolk and Suffolk NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The proposed Lorenzo enhancement cannot be implemented until clinical safety and information governance compliance are confirmed.
Verbatim wording from the response “2. In the interim the trust has commenced work on enhancing the current EPR, Lorenzo. We have identified a potential enhancement that will allow staff to indicate, when generating correspondence (including appointments) that the correspondence should also be sent to the Next of Kin or Carer, according to stated patient preference.” Source location Response from Norfolk and Suffolk NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No single technical solution can fully mitigate appointment communication risk; mitigation requires a range of actions.
Verbatim wording from the response “It is most often the case that routine appointments are communicated by letter however urgent or cancellation appointment offers may be made via text, email or through telephone calls based on the agreed method and timeframe to the appointment. This means there is no one single technical solution that will fully mitigate the risk but a range of actions.” Source location Response from Norfolk and Suffolk NHS
Open published response
30 May 2024 Katie MADDEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents View source See 4 more concerns
Responses linked to these concerns
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AI-generated summary
Katie MADDEN · 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
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of independent Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report
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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 Norfolk and Waveney Integrated Care Board is responsible for deciding individual funding requests for treatments unavailable through standard NSFT services.
Verbatim wording from the response “NSFT is commissioned to provide mental health services within Norfolk and Suffolk. For service users under the care of NSFT, where a need for treatment that cannot be provided by NSFT is clinically indicated by NSFT clinicians, a process for requesting individual funding is available by way of request to Norfolk & Waveney Integrated Care Board.” Source location Response from NSFT
Open published response
4 May 2024 Paul David TEMPLETON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to recognise elevated suicide risk from prolonged refusal to eat or drink View source Failure to recognise prolonged refusal to eat or drink as action to end life View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul David TEMPLETON · 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
Paul David Templeton died at Ipswich Hospital on 20 April 2023 following termination of life support after asphyxiation. The Jury found that prolonged refusal to eat or drink while detained under the Mental Health Act should have been recognised as action to end his life and as elevating his suicide risk, including by other means. The report raises concern that the response from Norfolk & Suffolk NHS Foundation Trust did not adequately address these failures in suicide risk assessment.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise elevated suicide risk from prolonged refusal to eat or drink
Wider context from the report “In the words of the Jury: “Initial and all subsequent assessments seriously fail to recognise that Paul’s prolonged choice not to eat or drink were in fact indications of ‘action’ to end his own life and therefore he should have been considered as a suicide risk .”
Action is needed to prevent future failure to recognise (a) when the prolonged choice of a patient detained under the Mental Health Act not to eat or drink should be regarded as an action to end their own life; and (b) when such a patient’s prolonged choice not to eat or drink should be recognised as elevating that patient’s suicide risk (including of suicide by means other than malnourishment).
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise prolonged refusal to eat or drink as action to end life
Wider context from the report “In the words of the Jury: “Initial and all subsequent assessments seriously fail to recognise that Paul’s prolonged choice not to eat or drink were in fact indications of ‘action’ to end his own life and therefore he should have been considered as a suicide risk.”
Action is needed to prevent future failure to recognise (a) when the prolonged choice of a patient detained under the Mental Health Act not to eat or drink should be regarded as an action to end their own life ; and (b) when such a patient’s prolonged choice not to eat or drink should be recognised as elevating that patient’s suicide risk (including of suicide by means other than malnourishment).
” Open source report
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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 Develop and deliver bespoke training linking suicide prevention with malnourishment, with subject-matter expert support.
Verbatim wording from the response “The challenge for the Trust is to secure a training package which sufficiently addresses both clinical risk assessment and food and nutrition. The national approved training, required as mandatory by the Trust, does not reference suicide through malnourishment. The Trust’s 3PS (Presenting, predisposing, precipitating, perpetuating & protective factor training) programme highlights the importance of good nourishment but does not link this to suicide. We recognise that to deliver content linking suicide prevention training with content referencing malnourishment we will need to develop and deliver a bespoke package of training supported by subject matter experts. We are in the process of discussing this with our Physical Health team and raising this with NHS England and the Royal College of Psychiatrists for their broader consideration.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Revise SBAR handover records to capture eating-and-drinking quantity, not only appetite, for clinical risk assessment.
Verbatim wording from the response “To ensure focus on appropriate clinical risk assessment, the Team are using Daily Team huddles to prompt assessors to consider holistic care / including eating and drinking within their clinical risk assessments. To support this, we have also made changes to the SBAR (Situation Background Assessment Recommendation) record that the team use to communicate and share patient information at handover. The revised SBAR provides more information about eating and drinking (identifying quantity not just appetite) to inform clinical risk assessment.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Use daily team huddles to prompt consideration of eating and drinking in holistic clinical risk assessments.
Verbatim wording from the response “To ensure focus on appropriate clinical risk assessment, the Team are using Daily Team huddles to prompt assessors to consider holistic care / including eating and drinking within their clinical risk assessments. To support this, we have also made changes to the SBAR (Situation Background Assessment Recommendation) record that the team use to communicate and share patient information at handover. The revised SBAR provides more information about eating and drinking (identifying quantity not just appetite) to inform clinical risk assessment.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Discuss food-and-drink risk assessment in clinical supervision and review it in future team meetings.
Verbatim wording from the response “In response to your concerns (a) & (b) we have acted to secure assurance that assessors working within Willows ward have the skills and awareness required to undertake comprehensive holistic risk assessments, including an understanding and awareness of the significance of food and drink in mental health risk assessment. A reflective Multi-Disciplinary Team (MDT) Away Day was held on 15th and 17th May 2024. During this, the team explored the application of clinical risk assessment skills to a range of different cases. This was undertaken to support the transition of knowledge into clinical practice and provide assurance of consistency between staff members. The case studies included scenarios related to food and drink to raise staff awareness. To maintain a good standard of clinical practice this will be discussed in clinical supervision and reviewed within future team meetings.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Hold a reflective multidisciplinary away day using food-and-drink case studies to strengthen holistic clinical risk assessment.
Verbatim wording from the response “In response to your concerns (a) & (b) we have acted to secure assurance that assessors working within Willows ward have the skills and awareness required to undertake comprehensive holistic risk assessments, including an understanding and awareness of the significance of food and drink in mental health risk assessment. A reflective Multi-Disciplinary Team (MDT) Away Day was held on 15th and 17th May 2024. During this, the team explored the application of clinical risk assessment skills to a range of different cases. This was undertaken to support the transition of knowledge into clinical practice and provide assurance of consistency between staff members. The case studies included scenarios related to food and drink to raise staff awareness. To maintain a good standard of clinical practice this will be discussed in clinical supervision and reviewed within future team meetings.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
28 Mar 2024 Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 13 Inadequate risk assessment in response to urgent referrals View source Unavailability of a handover document between shifts for urgent referral downgrading View source Inadequate decision making when downgrading urgent referrals View source Failure to introduce a screening tool for determining PSIRF implementation View source Incomplete and ineffective rollout of STORM training to staff View source Inadequate PSIRF processes for addressing serious patient incidents View source Failure to define which statements are to be taken for serious patient incident investigations View source Failure to retain recordings of calls for serious patient incident investigations View source Failure to implement the SOP for downgrading urgent referrals View source Failure by NSFT to implement the Patient Safety Incident Response Framework View source Failure to make adequate discharge decisions after failed engagement with mental health services View source Failure to preserve recordings of calls between patients and the crisis call handler View source Inadequate safety planning in response to urgent referrals View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ellen Ocean WOOLNOUGH · 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
Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate risk assessment in response to urgent referrals
Wider context from the report “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment , safety planning and decision making concerning the downgrading of referrals.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a handover document between shifts for urgent referral downgrading
Wider context from the report “ii. Whilst the downgrade policy concerning urgent referrals has been tightened up, key parts of the process, such as the handover document between shifts, is still to be introduced .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate decision making when downgrading urgent referrals
Wider context from the report “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to introduce a screening tool for determining PSIRF implementation
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented , the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete and ineffective rollout of STORM training to staff
Wider context from the report “i. STORM training continues to be rolled out , although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate PSIRF processes for addressing serious patient incidents
Wider context from the report “3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define which statements are to be taken for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations , are still to be introduced by the Trust.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain recordings of calls for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the SOP for downgrading urgent referrals
Wider context from the report “iii. The Trust SOP addressing the downgrading of urgent referrals , which I was told was revised in 2023, has not been provided to the Court and has not been implemented by the Trust .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by NSFT to implement the Patient Safety Incident Response Framework
Wider context from the report “3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make adequate discharge decisions after failed engagement with mental health services
Wider context from the report “1. The adequacy of Norfolk and Suffolk NHS Foundation Trust’s (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve recordings of calls between patients and the crisis call handler
Wider context from the report “v. The failure by NSFT to preserve important evidence , in the form of recordings of calls between Ellie and the NSFT crisis call handler , at a time when it was not on notice that this evidence would be important and relevant for the conduct of the Inquest, remains a concern.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate safety planning in response to urgent referrals
Wider context from the report “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals.
” Open source report
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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 Embed the updated handover document in East CRHTT practice.
Verbatim wording from the response “2. Whilst the downgrade policy concerning urgent referrals has been tightened up, key parts of the process, such as the handover document between shifts, is still to be introduced.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Update the Clinical Risk Assessment and Management Policy through governance, publish it, and progress its implementation plan.
Verbatim wording from the response “The Trust has recently been reviewing and updating their Clinical Risk Assessment and Management Policy. This Policy is currently progressing through Trust internal governance processes and is due to be published end of June 2024, with a Policy implementation plan to be progressed during July/August 2024. This will provide additional support to staff clinical risk assessment practice.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Extend call-recording capability across designated crisis-pathway phone lines, including the identified CRHTT area.
Verbatim wording from the response “Recognising that we have an extensive network of phone lines, we have also taken steps to secure assurance that the phone lines that we need recording, across the crisis pathways, are appropriately enabled. Through a detailed scoping exercise, we identified the need to extend our current recording facility in one of our CRHTT areas. This went live on 15th May 2024. All phone lines which have been designated as requiring recording facility have now been enabled.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Implement the updated Trust-wide CRHTT SOP and Clinical Harm Review SOP requirements for discussing urgent-referral regrading with another clinician.
Verbatim wording from the response “3. The Trust Standard Operating Procedure (SOP) addressing the downgrading of urgent referrals, which I was told was revised in 2023, has not been provided to the Court and has not been implemented by the Trust.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.
Verbatim wording from the response “4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Audit handover-document use monthly and report findings through local and Trust quality-assurance structures.
Verbatim wording from the response “To secure assurance that we are adhering to required practice when a referral is being considered for regrade, we have commenced an audit of the hand over document. An audit commenced week commencing 13.05.24. This audit will continue on a monthly cycle for assurance and improvement purposes.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Review and refresh the Education Strategy, including the STORM training offer and any further Trust-wide rollout.
Verbatim wording from the response “1. STORM© training continues to be rolled out, although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Evaluate compliance with two-clinician referral regrading through management monitoring and a Patient Safety and Quality Team audit, with results reported through quality-assurance structures.
Verbatim wording from the response “We will evaluate compliance against this standard through local management monitoring with additional second level assurance provided through an audit that will be completed by the Patient Safety and Quality Team by mid-July 2024. This will enable us to provide assurance that all decisions to regrade a referral are being made by two clinicians in line with Trust standard.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Establish consistent, information-governance-compliant retrieval of relevant patient-call recordings by the Patient Safety team.
Verbatim wording from the response “this screening form, to prompt the clinical team that are providing an initial description of the events that have occurred, to consider whether any patient calls are available for retrieval, so that they can be secured for investigation and inquest purposes. We have strong processes in place to ensure that the retrieval of these calls is undertaken in a consistent and IG compliant manner by members of the Patient Safety team.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
25 Mar 2024 Christopher Edward SIDLE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 8 Failure to fully and properly record the rationale for decisions View source Insufficient telephone-based support to recognise ongoing concerns View source Shortage of inpatient mental health beds View source Failure to circulate important emails to relevant CRHTT personnel View source Delays in arranging assessments for people requiring an immediate response View source Lack of understanding of mental capacity assessment View source Failure to conduct full and proper assessments and independently verify service users’ responses View source Lack of understanding of the scope and limitations of community team services View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Edward SIDLE · 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
Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully and properly record the rationale for decisions
Wider context from the report “3. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient telephone-based support to recognise ongoing concerns
Wider context from the report “4. Support provided by FACT is usually carried out by telephone and will in some circumstances not be sufficient to recognise ongoing concerns , for instance with regard to medication concordance .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of inpatient mental health beds
Wider context from the report “7. Evidence was heard of a nationwide shortage of inpatient mental health beds . Action has been taken by NSFT in an effort to minimise impact, but this does remain an ongoing concern .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate important emails to relevant CRHTT personnel
Wider context from the report “5. Important emails were not circulated to relevant personnel within the CRHTT . The evidence remains unclear what happened to the emails and why they did not reach the appropriate member of the team.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging assessments for people requiring an immediate response
Wider context from the report “6. A person can be identified at triage risk assessment as being in need of an “immediate response, within 4 hours” but an assessment is then arranged for within a 24-hour period .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of mental capacity assessment
Wider context from the report “3. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct full and proper assessments and independently verify service users’ responses
Wider context from the report “1. Despite additional face to face training being made available to the CRHTT, witness evidence was heard which does not reflect the findings of the investigation and does not recognise the need for a full and proper assessment and the need not to accept a service user’s response to questions raised .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the scope and limitations of community team services
Wider context from the report “2. There remains a lack of understanding amongst the CRHTT with regard to the scope and limitations of other services available within the community team .
” Open source report
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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 Hold weekly interface meetings between experienced CRHTT practitioners and community teams.
Verbatim wording from the response “In addition, within the Norfolk CRHTT, experienced practitioners attend weekly interface meetings with community teams to increase their knowledge of each other's service.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Deliver bespoke mental capacity training to CRHTT staff.
Verbatim wording from the response “Bespoke training was designed in response to the difficulties identified in Mr Sidle’s care. This was delivered by the Mental Capacity Act Lead (MCA) to the CRHTT involved in his care. This was an interactive session delivered through “Teams” on 01.05.24 & 02.05.24. Staff awareness will be further supported through discussion of case studies as part of table discussion, at the forthcoming CRHTT training day on 21 August 2024.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Routinely document clinical risk using the 5P formulation approach.
Verbatim wording from the response “Norfolk CRHTT is well established in utilising the 5P Formulation model in all interventions. This model refers to 5 factors (Presenting problem; Precipitating; Perpetuating; Predisposing; and Protective Factors) to support comprehensive understanding and formulation for care planning purposes.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Provide administrative and senior support-worker capacity to monitor the CRHTT inbox during weekday and weekend periods.
Verbatim wording from the response “To increase resilience, administrative support has now been allocated to assist the PIC with weekday administrative tasks which includes monitoring the inbox.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Operate one generic CRHTT email address with a defined process for qualified practitioners to check and action messages.
Verbatim wording from the response “These have now been merged into one generic team email address. The process for receipt and management of emails to the CRHTT generic team e mail address has been reviewed.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Undertake a FACT service scoping exercise and produce a cross-team review with recommendations and an action plan.
Verbatim wording from the response “An initial scoping exercise is being undertaken as part of Quality Improvement initiative led by the Deputy service director, to understand the existing arrangements and opportunities for improvement. in FACT delivery. This will report to the newly established (April 2024) Trust wide Safety Group to ensure there is consistency regarding the application of FACT. A review of existing FACT arrangements across the 5 Adult CMHTs in North Norfolk and Norwich inclusive of recommendations and a clear action plan, will be received by the Chief Nurse by 31st July 2024.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Monitor the impact of CRHTT measures through monthly audits and report findings through Trust quality and safety governance.
Verbatim wording from the response “We will monitor the impact of these measures on patient care and assessment by undertaking a monthly audit. This will inform an evaluation report that will be presented to the Care Group Quality Assurance Group for monitoring purposes and to support improvement. For assurance purposes the report findings will be presented to the Trust Safety group and onward to the Trust Board Quality Committee.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Implement the updated Trust-wide CRHTT standard operating procedure covering team liaison, service scope and referral regrading.
Verbatim wording from the response “In May 2024 an updated Trust wide CRHTT Standard Operating Procedure (SOP) was ratified and implemented across the Trust.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Implement monthly mental capacity audits locally and Trust-wide, reporting findings through quality and safety governance.
Verbatim wording from the response “To provide assurance that CRHTT apply their MCA knowledge consistently and appropriately, an audit programme has been developed. A monthly audit will go live in Norfolk CRHTT on 20.05.24. We will use our audit findings and other means (for example feedback from patient safety investigations), to identify ongoing training needs. We will provide bespoke training where this is identified as needed. This bespoke training offer is in addition to the Trust’s existing requirement for all clinical assessors to receive mandatory e learning training in mental capacity every three years.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Audit implementation of the CRHTT email-management and night-handover processes over six months.
Verbatim wording from the response “Night shift is covered by 2 clinicians and 2 senior support workers with shared responsibility. All contacts are recorded on to the Night Handover Log. The embedding of this new process will be monitored through a six-month audit which will commence 20.05.24.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Develop and establish a core competency framework for CRHTT assessors.
Verbatim wording from the response “Nevertheless, in response to this incident and as presented at inquest, the Trust has developed a core competency framework for CRHTT assessors which reflects fidelities outlined within the Core CRISIS Fidelity Scale. This was developed by 31.08.23 in response to an action arising from the Safety Incident Review (SIR) that was undertaken by the NSFT Patient Safety Team. Our action was to ensure that new assessing staff complete an induction and all assessors within the team complete core competency.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Recruit qualified, experienced CRHTT clinicians and provide a structured 12-week preceptorship, supervision and development portfolio.
Verbatim wording from the response “It is acknowledged that clinicians within CRHTT require a wide breadth of knowledge and understanding and as such in April 2024 a recruitment and retention project was launched for CRHTT. This project will attempt to recruit qualified and experienced clinicians, these will be qualified band 5 with post registration experience. They will undertake a 12-week preceptorship within CRHTT. New staff will be allocated to a named preceptor. Their preceptor will be an experienced member of staff who will act as their professional support during their induction to the CRHT Team. New team members will be expected to complete 80% of clinical time with their preceptor within their first 12 weeks. They will attend weekly supervision and monthly reflective practise, as well as complete a portfolio that will record evidence of their training and professional development.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Discuss mental capacity case studies during the forthcoming CRHTT training day.
Verbatim wording from the response “Bespoke training was designed in response to the difficulties identified in Mr Sidle’s care. This was delivered by the Mental Capacity Act Lead (MCA) to the CRHTT involved in his care. This was an interactive session delivered through “Teams” on 01.05.24 & 02.05.24. Staff awareness will be further supported through discussion of case studies as part of table discussion, at the forthcoming CRHTT training day on 21 August 2024.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Complete induction, competency assessment and supervised competency development for CRHTT assessing staff.
Verbatim wording from the response “Nevertheless, in response to this incident and as presented at inquest, the Trust has developed a core competency framework for CRHTT assessors which reflects fidelities outlined within the Core CRISIS Fidelity Scale. This was developed by 31.08.23 in response to an action arising from the Safety Incident Review (SIR) that was undertaken by the NSFT Patient Safety Team. Our action was to ensure that new assessing staff complete an induction and all assessors within the team complete core competency.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 The witness evidence does not reflect the investigation findings or recognise the need for full assessment of service users’ responses.
Verbatim wording from the response “1. Despite additional face to face training being made available to the CRHTT, witness evidence was heard which does not reflect the findings of the investigation and does not recognise the need for a full and proper assessment of the need to accept a service user’s response to questions raised.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
26 Sep 2022 Lewis Robert BEGLEY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to determine whether and how much medication has been taken after patient access View source Lack of fixed training for doctors on administering medication during suspected drug overdoses View source Lack of records of stored medication and quantities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lewis Robert BEGLEY · 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
Lewis Robert Begley was admitted to a mental health ward on 12 December 2020 and was found unresponsive in his room on the morning of 15 December 2020 after accessing the medicine room. He was pronounced dead at the scene, and post-mortem examination found a split plastic bag containing tablets in his rectum. Concerns included inadequate recording of medicines held, limited knowledge of what medication may have been taken after patient access, and a lack of fixed training for doctors regarding suspected overdoses.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether and how much medication has been taken after patient access
Wider context from the report “2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much , thereby limiting knowledge as to what treatment is to be considered and what action to be taken
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of fixed training for doctors on administering medication during suspected drug overdoses
Wider context from the report “3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of ████████ in the event of there being a suspected drugs overdose .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of records of stored medication and quantities
Wider context from the report “1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much , particularly ████████ which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard.
” Open source report
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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 training staff to administer the resuscitation drug for suspected or known opiate overdose in line with Resuscitation Council UK guidelines.
Verbatim wording from the response “3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of ████████ in the event of there being a suspected drugs overdose.
In line with other mental health trusts, we will continue to train staff and stock ████████ as part of the resuscitation response adhering to the Resuscitation Council UK guidelines, both nurses and medics are able to administer this drug to reverse a suspected or known opiate overdose.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Transfer Safe and Secure Handling of Medication audits to Pharmacy leadership and accountability.
Verbatim wording from the response “• Safe and Secure Handling of medication audit will now be led by Pharmacy, this is a change in process and accountability and address the issues of stock oversigh[t] within ward areas.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
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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 Medics will not be trained to administer the antidote because the skill cannot be maintained without regular use.
Verbatim wording from the response “In respect of ████████ and in line again with other mental health trust we will continue to stock ████████ as a potential antidote to a suspected or known ████████ overdose; in case there is a medic available who is experienced and able to administer. However, we will not train our medics to administer this as the skill cannot be maintained without regular use. To note in our internal review the ambulance trust advised that the ambulance crews and paramedics do not administer this drug unless they have a specialist medic on the team for the same reason.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
22 Aug 2022 Eliot HARRIS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 9 Failure to allocate specific tasks to staff on night duty View source Failure to allocate a Nurse in Charge for each night’s rota View source Retrospective process for carrying out relevant and requested physical health checks View source Failure to fully record Multi Team Meetings and decision rationales in clinical records View source Failure to ensure immediate staff entry to a patient’s room when welfare concerns arise View source Failure to maintain up-to-date Care Plans View source Failure to record observations in accordance with policy View source Lack of staff training and competency assessment for carrying out observations View source Failure to carry out observations in accordance with policy View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Eliot HARRIS · 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
Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.
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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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate specific tasks to staff on night duty
Wider context from the report “2) On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs . The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate a Nurse in Charge for each night’s rota
Wider context from the report “2) On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs. The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Retrospective process for carrying out relevant and requested physical health checks
Wider context from the report “6) It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out . The process of ensuring health checks are carried out has not changed since Eliot’s death and remains a retrospective process
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully record Multi Team Meetings and decision rationales in clinical records
Wider context from the report “3) Multi Team Meetings were not fully and properly recorded in the clinical records . At the inquest, evidence was heard there “is still some way to go” with regard to improving record keeping and for ensuring important matters such as rationale for decisions is fully recorded
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediate staff entry to a patient’s room when welfare concerns arise
Wider context from the report “5) Staff were reluctant to enter Eliot’s room following concern for his wellbeing . The evidence did not reveal what is now in place to ensure staff enter a patient’s room immediately if there are concerns for a patient’s welfare (having considered their (staff’s) own safety)
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date Care Plans
Wider context from the report “4) Eliot’s Care Plan was not up to date at the time of his death . At the inquest evidence was heard that although audits show there has been an improvement in completion of Care Plans, there “is still some way to go” and staff still need to be prompted to complete these
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations in accordance with policy
Wider context from the report “1) Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and competency assessment for carrying out observations
Wider context from the report “1) Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out observations in accordance with policy
Wider context from the report “1) Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations
” Open source report
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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 Refresh staff understanding of the therapeutic observations policy through competency reassessment.
Verbatim wording from the response “Locally, within Great Yarmouth Acute Service the team have implemented a Safety Day, which is training specifically developed for the ward and includes sessions on clinical risk assessment, care planning, learning from incidents with a detailed focus on therapeutic observations policy. To date, 19 of the 27 staff have attended the day with two further days planned. In addition, the Matron is leading on refreshing staffs understanding of the therapeutic observation policy by re-completion of the competency assessment.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Share learning from the inquest with ward staff through a scheduled Registered Nurses Day.
Verbatim wording from the response “Learning from the inquest has been shared with the ward team which has included the vital importance of completing therapeutic observations in line with the policy. The learning will be further shared within a Registered Nurses Day scheduled for November.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Monitor MDT meeting quality monthly and provide results and feedback to the ward team.
Verbatim wording from the response “Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high quality effective care. Record keeping is an essential action to support the evidence of care provided. The ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT review. This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which demonstrated on sustained improvement. An anonymised copy of the audit is attached. The changes are being monitored on a monthly basis with results fed back to the team by the Nurse Consultant.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Review the Therapeutic Observations Policy to consider strengthened training, documentation, ward controls, staff guidance and assurance processes.
Verbatim wording from the response “The goal of improving the application of therapeutic observations is important with a continuing improvement and monitoring focus. Training and audits form parts of the system to manage the safety and quality. The Trust is commencing a planned review of the Therapeutic Observations Policy, examining options to strengthen all areas including training, documentation, ward controls, guidance for staff and assurance processes. In addition, the ward has reviewed and significantly enhanced their local induction process which is overseen by the Clinical Team Leader.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Improve MDT record completeness using a meeting aide memoire and recorded daily brief reviews of patients.
Verbatim wording from the response “Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high quality effective care. Record keeping is an essential action to support the evidence of care provided. The ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT review. This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which demonstrated on sustained improvement. An anonymised copy of the audit is attached. The changes are being monitored on a monthly basis with results fed back to the team by the Nurse Consultant.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Strengthen care-plan completion and review through primary-nursing allocation, audit and Clinical Team Leader management supervision.
Verbatim wording from the response “As an individual’s care and treatment progresses, the ward employs a process to support the completion and revisions to of care plans as an individual’s care and treatment progresses. This includes strengthening the wards systems through the allocation of primary nursing responsibilities and the use of audit to monitor required improvements. The process provides feedback Clinical Team Leader leads the review of care plans and other clinical documentation as part of management supervision, all of which will enable further improvements. The care plans are used alongside the multi-disciplinary team meetings and handovers to support communication of care amongst the team” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Implement the Dialog+ recovery-focused care plan with supporting staff training and individual support sessions.
Verbatim wording from the response “Care plans provide details of the agreed interventions between the patient, family and team to support an individual’s recovery. Alongside other clinical documents, they assist the staff in their communication of the assessed needs of the individual, and the actions being taken. In November 2021, the Trust started the process of implementing a new style of care plan referred to as Dialog +. This care plan is recovery focused and is designed to work with the patient to understand the areas of their life which are important to them which they wish to improve. As part of the implementation within the ward, a training session was held within the Safety Day and the team awayday which were further supported by individual sessions with staff when required.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Strengthen the therapeutic-observations policy guidance on entering rooms during immediate welfare concerns and seeking help for staff safety.
Verbatim wording from the response “Supporting people, during times of risk and harm, as soon as it is safe to do so is important part of providing good care. Through our physical interventions training we promote consideration of safety, accompanied with message to seek support. Alongside this consideration of safety, human factors can influence people’s thinking when experiencing unfamiliar or intense situations. We are therefore seeking insights from other mental health Trusts as to any actions and programmes that they apply. In addition, the Safety Day includes a session on the Therapeutic Observation policy which includes a discussion on entering a room when there are immediate concerns for the patient’s welfare and how seek help if there are potential concerns for their own safety. This message has been strengthened within the Therapeutic Observations ‘Policy on a Page’” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Ensure each shift identifies a nurse in charge and allocates roles using the reviewed daily allocation process.
Verbatim wording from the response “Clarity of role within a shift is important to ensure all the required actions are completed in an effective way. The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse-in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. Additional to this aspect the trust is formulating a seminar on shift co-ordination and accountability this will be rolled out to all Charge Nurses including those joining from an agency, the timescale for sign off of this is three months.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Deliver ward-specific Safety Day training on clinical risk, care planning, incident learning and therapeutic observations.
Verbatim wording from the response “Locally, within Great Yarmouth Acute Service the team have implemented a Safety Day, which is training specifically developed for the ward and includes sessions on clinical risk assessment, care planning, learning from incidents with a detailed focus on therapeutic observations policy. To date, 19 of the 27 staff have attended the day with two further days planned. In addition, the Matron is leading on refreshing staffs understanding of the therapeutic observation policy by re-completion of the competency assessment.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
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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 Use handover and diary systems to keep physical-health-check actions open until completed.
Verbatim wording from the response “To meet this priority the Trust has a Physical Health Policy which provides guidance for staff on the practical actions to take in completing an initial physical health assessment. Understandably, an admission to hospital is an intensive, worrying time for people and they may not be able to initially engage in the assessment. The policy directs action of follow up attempts to complete this. The ward had made changes following Eliot’s death applying this through their handover and diary systems which support keeping an action open until completed.” Source location Response form Norfolk and Suffolk Foundation Trust
Open published response
11 Apr 2022 Tracy Dawn WOOD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 19 Failure to record important clinical events and patient discussions View source Failure to ensure accuracy of staff statements used in patient safety investigations View source Failure to investigate the source and nature of a hazardous item after an incident View source Failure to review hourly observations after a serious incident View source Failure to recover and check restricted items when patients return to the ward View source Insufficient ward staffing for required one-to-one patient support View source Inaccuracies in patient safety incident investigation reports View source Lack of clinical or management leadership supervision on the ward View source Inaccurate dates and times in clinical records View source Failure to interview relevant staff during patient safety investigations View source Delays in completing and providing patient safety incident investigation reports View source Delayed availability of emergency life-saving equipment at the patient’s room View source Failure to provide timely psychiatric doctor assessment when requested View source Incident investigations failing to establish the sequence of safety-critical events View source Patient safety investigations omitting relevant incident and record-keeping concerns View source Failure to document multidisciplinary observation decisions in clinical notes View source Failure to record administration of hazardous items and the rationale for overriding restrictions View source Failure to obtain clinical authorisation before overriding restrictions on hazardous items View source Ambiguous scope of restrictions on giving hazardous items to patients View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tracy Dawn WOOD · 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
Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record important clinical events and patient discussions
Wider context from the report “8. Certain events are not included in the records , for example that a ████████ had been given to Tracy on 1 June 2021 on her going off ward , contrary to the instruction contained in the SBAR records and of 121 Talk times with Tracy. Evidence was heard that steps are being taken to improve record keeping. However this matter has been raised with NSFT previously and evidence from one witness at the inquest was that “every discussion” with a service user is recorded in the Clinical Record and that entries are made by one allocated person on a shift who will be told orally what to put by members of staff. This witness had had a 30 to 40 minute one to one meeting with Tracy the day prior to her ████████ on 1 June and talk time with Tracy on the day following her ████████ on 1 June, details of which may have been helpful to other staff and regarded of some importance to Tracy’s care
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accuracy of staff statements used in patient safety investigations
Wider context from the report “14. The PSII stated that statements of members of staff “for the Coroner” were reviewed. However many of these statements contained inaccurate dates and times including the date of death .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the source and nature of a hazardous item after an incident
Wider context from the report “5. Following Tracy ████████ on the evening of 1 June 2021, there was no investigation as to where she obtained the ████████ , despite there being a bold, red instruction in the SBAR records that Tracy was not to be given a ████████. By the date of the inquest some witnesses were still unaware as to how Tracy had come by the ████████ with. Some witnesses were still unaware as to what Tracy had used as a ████████
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review hourly observations after a serious incident
Wider context from the report “6. Following Tracy ████████ on 1 June 2021, there was a review meeting and then a Multi Disciplinary Team Meeting. She had a meeting with the Psychologist later that day. No evidence was heard that there was a review of hourly observations
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recover and check restricted items when patients return to the ward
Wider context from the report “4. Part of the Risk Assessment for giving a ████████ to Tracy was that she was to hand the ████████ back on her return to the ward. Tracy did not return the ████████ and was not asked to return the ████████ . That Tracy had been given an ████████ was overlooked on her return .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ward staffing for required one-to-one patient support
Wider context from the report “1. Tracy Wood was placed on Yare Ward, an acute ward which was staffed in accordance with “Safer staffing levels”. We heard that additional staffing could be requested if necessary. The ward was described by witnesses as “busy” and at times “chaotic”. Staff were not always available to give Tracy one to one talk time which was recognised as being important to her and for her mental wellbeing, so much so a note was placed in red and bold on her SBAR records “If we are allocated to TW 1-1 we need to make sure we are doing it, she needs consistency”. Evidence was heard that steps are being taken to recruit more staff and also to retain existing staff and this is a national problem. The evidence was that the staffing levels are still not sufficient and that recruiting staff remains a problem
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in patient safety incident investigation reports
Wider context from the report “11. The PSII Report contains many inaccuracies including Tracy’s date of death, stating it to be 5 June 2021. The report refers to Tracy ████████ again at 21:00 on 3rd June 2021. The correct date is the 2 June 2021
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical or management leadership supervision on the ward
Wider context from the report “16. The first draft of the PSII Report contains a sentence “However, staff noted there was a lack of clinical or management leadership supervision on the ward at the time and they were often left to “firefight” with patients who they perceived carried a greater level of acute risk than Tracy.” This view of staff was not included in the final draft Report
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate dates and times in clinical records
Wider context from the report “7. Written records did not specify correct dates and times as to events , for instance the Event Date/Time of the ████████ incident on 1 June 2021 at 20:53 hours is recorded in the Clinical Notes as “02 Jun 2021 06:49”. Tracy’s date of death is recorded as 5 June 2021 and her date of birth in the SBAR records is recorded as 1 May 1981, when it is the 1 June 1981 .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to interview relevant staff during patient safety investigations
Wider context from the report “13. The PSII did not involve interviews with members of staff who had involvement with Tracy in the hours and days prior to her death , including staff who gave the ████████ to Tracy and a Nurse who had regular involvement with Tracy’s care and who knew her well
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing and providing patient safety incident investigation reports
Wider context from the report “10. A draft Patient Safety Incident Investigation Report (PSII) has been prepared. Evidence was heard that this is now used rather than a Serious Incident Requiring Investigation Report and has the advantage of being “more timely” and providing more learning. The report was still in draft form at the date of the inquest (nine months following Tracy’s death) and the draft was only available to me on the morning of the first day of the inquest , despite assurances at Pre Inquest Review Hearings that it would be available prior to the inquest.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed availability of emergency life-saving equipment at the patient’s room
Wider context from the report “9. On Tracy being found on the 2 June 2021 with a ████████ around her neck, emergency life-saving equipment was not brought immediately to Tracy’s room . Monitoring equipment was obtained by a member of staff who gave evidence they were unaware Tracy was not breathing . On return to Tracy’s room the emergency “crash bag” was then requested and obtained .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely psychiatric doctor assessment when requested
Wider context from the report “2. Following Tracy ████████ on the evening of 1 June 2021 the Duty Psychiatric Doctor was called to attend to see and assess Tracy, but did not attend . She was assessed by nursing staff but she was not seen by a Psychiatric Doctor as requested by them, until the next morning during a review meeting
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incident investigations failing to establish the sequence of safety-critical events
Wider context from the report “12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ████████ with a ████████ but goes on to say that in interviews a cord from her ████████ was used. Confusion remains as between the events on the 1 June 2021 and the 2 June 2021 . The report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly observations. There is no reference in the Clinical Notes to observations being discussed. Witnesses asked about observations at the inquest could not recall observations being discussed or that they were not discussed.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Patient safety investigations omitting relevant incident and record-keeping concerns
Wider context from the report “15. The PSII does not make findings with regard to areas of concern raised at the inquest such as with regard to Tracy being given a ████████ on the morning of 1 June 2021 despite there being a bold red note contained in the records that Tracy should not be given a ████████, that this was not discussed with any other senior member of staff, no record was made of the decision and the rationale for the decision, nor that the ████████ was not returned on Tracy’s return. The PSII does not include reference to inaccurate record keeping and full records of important events not being kept .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document multidisciplinary observation decisions in clinical notes
Wider context from the report “12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ████████ with a ████████ but goes on to say that in interviews a cord from her ████████ was used. Confusion remains as between the events on the 1 June 2021 and the 2 June 2021. The report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly observations. There is no reference in the Clinical Notes to observations being discussed . Witnesses asked about observations at the inquest could not recall observations being discussed or that they were not discussed .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record administration of hazardous items and the rationale for overriding restrictions
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward. There was no discussion with a Doctor or any other clinical staff when making this decision. There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain clinical authorisation before overriding restrictions on hazardous items
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward. There was no discussion with a Doctor or any other clinical staff when making this decision . There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguous scope of restrictions on giving hazardous items to patients
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward . There was no discussion with a Doctor or any other clinical staff when making this decision. There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” Open source report
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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 Routinely upload the SBAR tool onto the electronic patient record.
Verbatim wording from the response “The SBAR tool is now routinely uploaded onto the electronic record.” Source location Response from Hellesdon Hospital
Open published response
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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 Implement improvements to the clinical handover format.
Verbatim wording from the response “In discussion with the Matron for this area her account is that the Duty Doctor was asked to attend however had to prioritise other tasks given that Tracy was unharmed and responding well to 1:1 discussion with the staff on the ward. This is reflected in the patient record. The next morning Tracy was seen by her regular doctor when he knew her well. It is noted within the record that the ward staff were aware the Duty Doctor had not been able to attend but they did not escalate any further concerns for the reasons stated. However, it is not clear if the Duty Doctor discussed this decision with the senior on-call medic; an action for the Trust has been to improve the induction for junior and trainee doctors to include the escalation process for both psychiatric and physical health concerns and to implement improvements to the handover format.” Source location Response from Hellesdon Hospital
Open published response
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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 Improve junior and trainee doctor induction to cover escalation of psychiatric and physical health concerns.
Verbatim wording from the response “In discussion with the Matron for this area her account is that the Duty Doctor was asked to attend however had to prioritise other tasks given that Tracy was unharmed and responding well to 1:1 discussion with the staff on the ward. This is reflected in the patient record. The next morning Tracy was seen by her regular doctor when he knew her well. It is noted within the record that the ward staff were aware the Duty Doctor had not been able to attend but they did not escalate any further concerns for the reasons stated. However, it is not clear if the Duty Doctor discussed this decision with the senior on-call medic; an action for the Trust has been to improve the induction for junior and trainee doctors to include the escalation process for both psychiatric and physical health concerns and to implement improvements to the handover format.” Source location Response from Hellesdon Hospital
Open published response
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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 Ensure agency staff can access electronic patient records and understand expectations to record contemporaneous notes individually and comprehensively.
Verbatim wording from the response “There have been some ICT barriers to agency staff accessing the electronic patient record historically however this is being corrected to ensure that all staff have access and are aware of the expectation to record contemporaneous notes individually and comprehensively, see response to question 7.” Source location Response from Hellesdon Hospital
Open published response
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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 Increase therapeutic inpatient activities, including one-to-one time, exercise, fitness and arts and crafts, through a quality improvement project.
Verbatim wording from the response “The inpatient wards are part of a quality improvement project to enhance and increase therapeutic activities including 1:1 time, exercise and fitness, external and ward-based art and craft activities amongst other initiatives.” Source location Response from Hellesdon Hospital
Open published response
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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 Ensure review authors do not repeat the omission of relevant safety concerns in future reviews.
Verbatim wording from the response “It transpires the SBAR was a document not uploaded onto the electronic record. This led to the author not being aware of the SBAR and reporting on what was in the electronic record only, this was a gap in attention to detail. This aspect regarding the risk posed by the bandage should have been included in the review and was an omission, the author of the review has reflected on this and will ensure this is not repeated.” Source location Response from Hellesdon Hospital
Open published response
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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 Maintain a permanent Consultant Psychiatrist and increase senior nursing capacity through Deputy Lead Nurse, Matron and Clinical Nurse Specialist appointments.
Verbatim wording from the response “At the time of Tracy’s stay on this ward the ward did not have a permanent Consultant Psychiatrist, this has since changed and a permanent medic is in situ, this appointment supports the multi-disciplinary team in providing consistency which in turn brings stability to the ward environment. Equally the senior nursing presence has been increased with the recruitment of a Deputy Lead Nurse to support the Lead Nurse and enhancing the Matron and Clinical Nurse Specialist cohort across the hospital site.” Source location Response from Hellesdon Hospital
Open published response
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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 Recruit and retain inpatient staff to bring staffing within safe limits across clinical disciplines.
Verbatim wording from the response “The Trust has committed to ensure that staffing on all our inpatient areas is within safe limits this includes nurses, support workers and other allied health professionals as well as medical staff. In response to vacancies, within the context of a national shortage and retention crisis of staff in the NHS, the Trust has embarked on an ambitious recruitment campaign which includes holding recruitment fairs across the region, attracting overseas nurses, social media campaigns, full page adverts in national newspapers, medical and nursing journals, continual refreshed adverts on the NHS Jobs website, incentives and improved development opportunities.” Source location Response from Hellesdon Hospital
Open published response
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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 Provide staff training on contemporaneous, high-standard record keeping through an external law firm.
Verbatim wording from the response “The issue of contemporaneous record keeping of a high standard is a priority for the Trust and we have commissioned an external law firm to provide training to staff on this subject. This will be underway within the next 6-8 weeks.” Source location Response from Hellesdon Hospital
Open published response
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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 Agency staff were not compelled to participate in Trust reviews, preventing interviews with some staff involved in Tracy’s care.
Verbatim wording from the response “The staff who were not spoken to were agency staff who are not compelled to comply with Trust reviews despite the obvious ethical and professional drivers to do so. In this review one agency staff member approached did make himself available however a female staff member did not. However, the review panel were content that the staff who did engage knew Tracy well and were able to give a consistent account of events as they knew them, this included a range of professionals: nursing, occupational therapy, psychology, and psychiatry.” Source location Response from Hellesdon Hospital
Open published response
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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 The review panel considered accounts from participating staff and professionals sufficient despite some agency staff not being interviewed.
Verbatim wording from the response “The staff who were not spoken to were agency staff who are not compelled to comply with Trust reviews despite the obvious ethical and professional drivers to do so. In this review one agency staff member approached did make himself available however a female staff member did not. However, the review panel were content that the staff who did engage knew Tracy well and were able to give a consistent account of events as they knew them, this included a range of professionals: nursing, occupational therapy, psychology, and psychiatry.” Source location Response from Hellesdon Hospital
Open published response
15 Feb 2022 Theo Jude BRENNAN-HULME · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment View source Persistence of a bullying and harassment culture within the Crisis Resolution Home Treatment Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Theo Jude BRENNAN-HULME · 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
Theo Brennan Hulme, a university student with Asperger’s Syndrome, a history of deliberate self-harm and suicidal thoughts, was found hanging in his room on 12 March 2019 and declared dead at the scene. The report identified concerns about the adequacy and timeliness of his mental health assessment, failure to make reasonable adjustments or involve his family, lack of follow-up after a missed appointment, a persistent culture within the Crisis Resolution Home Treatment Team, and the absence of an immediate review when a person is discharged after assessment.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment
Wider context from the report “2. Following an Assessment, a person is still discharged from the Community Team without any immediate “check” or discussion as to the correctness of this decision . It was heard that following Theo’s death immediate discharge from the Community Team following assessment is relatively rare. In these circumstances, such a discussion would not place an onerous burden on the Team and would enable a review of the discharging decision to be undertaken to ensure it is the correct decision.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Persistence of a bullying and harassment culture within the Crisis Resolution Home Treatment Team
Wider context from the report “1. Evidence was heard of a historic culture of bullying and harassment within the Crisis Resolution Home Treatment Team which has led to a loss of compassion in some instances with the view that some suicides are ‘inevitable’ and some reluctance to recognise when cases should be referred to the Team . Work has been undertaken by the Trust to improve such cultural attitudes. However, it was recognised in evidence that there is “still a distance to go” and areas where the culture needs to change . It is of concern that this culture remains three years following Theo’s death
” Open source report
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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 Maintain confidential and direct routes for staff to raise concerns, including senior leaders, the Freedom to Speak Up Guardian and Cultural Champions.
Verbatim wording from the response “The team have worked hard to challenge, address and improve in respect of a “bullying” culture, in part this has been progressed through the change in management of the team, away days and renewed focus on staff wellbeing. This includes ensuring that the team are aware of how to raise concerns whether in confidence or directly to senior leaders within the organisation, or through the Freedom to Speak Up Guardian and/or Cultural Champions in post across all service lines.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
Open published response
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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 Improve team culture through management changes, away days and a renewed focus on staff wellbeing.
Verbatim wording from the response “The team have worked hard to challenge, address and improve in respect of a “bullying” culture, in part this has been progressed through the change in management of the team, away days and renewed focus on staff wellbeing. This includes ensuring that the team are aware of how to raise concerns whether in confidence or directly to senior leaders within the organisation, or through the Freedom to Speak Up Guardian and/or Cultural Champions in post across all service lines.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
Open published response
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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 Undertake targeted listening events with teams across the Trust as part of the cultural improvement strategy.
Verbatim wording from the response “The Trust has a Staff Support Service which can be accessed by self-referral or managers are able to refer staff directly this service offers therapeutic support, as well as the usual occupational health support available. Staff also have access to Human Resources and/or Union representatives who are able to support with employment issues. The Executive team, including myself, also offer direct access for any staff member to speak to us or raise concerns through our open Hear to Listen sessions which are held weekly and invariably chaired by an Executive, contact through these forums can be anonymous if required. We also are undertaking targeted listening events with all teams across the Trust as part of our cultural improvement strategy.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
Open published response
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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 Use the live Q&A and supporting paper as agenda items across at least four team meetings to capture staff reflection and challenge perceptions.
Verbatim wording from the response “• Supporting paper written by Dr ████████ Magical thinking and moral injury: exclusion culture in psychiatry BJPsych Bulletin Vol 46 issue 1. 2021.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
Open published response
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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 Require young people to be seen or contacted before discharge through an implemented triage tool, including contact with referrers and significant others where appropriate.
Verbatim wording from the response “In response to your second concern, I would like to draw your attention to the extensive safety action plan put in place by the Norfolk Youth Teams post the deaths of young people in those teams in 2021, this has been discussed at the subsequent inquests into the deaths of those young people therefore I will not repeat the safety actions here. The salient aspects in respect of Theo’s case being that the Clinical Director for the Norfolk Youth Teams has implemented a triage tool which includes the directive that no young person is discharged without being seen face to face or contacted via phone or virtual contact if face to face not possible, plus the referrer and any significant other where appropriate.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
Open published response
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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 discharge safeguards require contact, case-by-case decisions, multidisciplinary communication and follow-up to support safe discharge decisions.
Verbatim wording from the response “In response to your second concern, I would like to draw your attention to the extensive safety action plan put in place by the Norfolk Youth Teams post the deaths of young people in those teams in 2021, this has been discussed at the subsequent inquests into the deaths of those young people therefore I will not repeat the safety actions here. The salient aspects in respect of Theo’s case being that the Clinical Director for the Norfolk Youth Teams has implemented a triage tool which includes the directive that no young person is discharged without being seen face to face or contacted via phone or virtual contact if face to face not possible, plus the referrer and any significant other where appropriate.” Source location 2022-0049-Response-from-Hellesdon-Hospital_Published
Open published response
10 Feb 2022 Sheila Elizabeth Steggles · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Failure to recognise reduced mobility as a risk factor and take appropriate steps View source Failure to perform and document VTE risk assessments after reduced mobility from baseline View source Failure of junior staff to seek senior advice about anticoagulation interactions before administration View source Failure of staff to be aware of patients’ relevant past medical history View source Failure to record specific review plans in care plans View source Insufficient detail about patients in clinical notes View source Failure to document specific staff concerns in clinical notes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheila Elizabeth Steggles · 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
Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise reduced mobility as a risk factor and take appropriate steps
Wider context from the report “Irrespective of the reason for a person’s mobility reducing, if it does so and this is a known risk factor then notice must be taken of it and appropriate steps taken .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform and document VTE risk assessments after reduced mobility from baseline
Wider context from the report “Medical staff should follow the Trust’s protocols and perform and document a VTE risk assessment when the reduction in mobility is reduced (from their baseline) even if it is not known if/ how long the reduction will continue.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of junior staff to seek senior advice about anticoagulation interactions before administration
Wider context from the report “Junior staff should consult more senior staff if they are unsure of the effect that anti-coagulation will have on anti-psychotics or other medication and are thus concerned about administering this .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to be aware of patients’ relevant past medical history
Wider context from the report “All staff should be aware of a patient’s relevant past medical history .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record specific review plans in care plans
Wider context from the report “If a patient is to be reviewed then a specific plan should be placed on to the care plan so that everyone knows what is needed to be done .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail about patients in clinical notes
Wider context from the report “All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document specific staff concerns in clinical notes
Wider context from the report “All staff should raise concerns and if they have specific ones, document what these are in the clinical notes . Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts.
” 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 Roll out face-to-face bite-size physical-health training across the Trust, including VTE and thrombolisation.
Verbatim wording from the response “All agency and bank staff will be offered the “3 Ps” training which covers “Prevent, Promote, Protect” – observations and assessment, health promotion and screening. This will be available to all staff from support worker to ward manager level, the format is a set of e-learning modules accompanied by a workbook. The physical health team are rolling out “bite size” training across the trust including focus on VTE and thrombolisation, this training will be face to face. We have set up a working group to work with our flexible working colleagues to support an education ‘passport’ for health workers which will include; acute and chronic conditions, NEWS2 (deteriorating patient), managing Insulin and use of protective personal equipment (infection control measures) amongst other subjects.” Source location 2022-0042-Response-from-Hellesdon-Hospital_Published
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 Use and build the SBAR tool in patient records during handovers and ward reviews to capture patient history, concerns and required escalation.
Verbatim wording from the response “Handover between junior Doctors and other medical staff will be underpinned by the Situation Background Assessment Recommendation (SBAR) framework. This will ensure that patient history, emerging concerns and necessary action including escalation where necessary are known, recorded and acted on. Inpatient wards across the organisation utilise and upload the SBAR tool into patient records to assist with ward reviews and handovers. The SBAR document is built upon at each handover, therefore building up a comprehensive history of the patient.” Source location 2022-0042-Response-from-Hellesdon-Hospital_Published
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 Update medical trainee, local and junior doctor induction materials to cover physical health emergencies, diagnostic overshadowing, VTE assessment, prophylaxis and escalation guidance.
Verbatim wording from the response “Actions taken above the recommendations within the internal review are primarily to address the gaps in junior Doctors understanding and prompts to escalate concerns regarding physical health. To this end the Medical Director for medical trainees will be updating the Trust induction to include physical health” Source location 2022-0042-Response-from-Hellesdon-Hospital_Published
Open published response
20 Oct 2021 Mary Jane BUSH · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to recruit, retain and resource suitably skilled staff View source Delays in access to psychological therapy View source Delays in mental health assessment following referral View source
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
Mary Jane BUSH · 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
Mary Jane BUSH, who had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, was found at her home on 6 August 2020; the inquest conclusion was suicide. The principal concerns were delays in her mental health assessment and psychological therapy, ongoing delays in providing therapy, and difficulties with recruitment and retention of suitably skilled staff.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit, retain and resource suitably skilled staff
Wider context from the report “5. However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust and the ability to resource this to enable the Trust to function effectively
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to psychological therapy
Wider context from the report “2. There was a delay in Mary receiving psychological therapy. She was still on the waiting list at the time of her death.
3. The evidence was that at the date of inquest, there continued to be a delay in service users receiving psychological therapy . Evidence was heard that balancing capacity and demand, which has increased, remains a challenge. The cases referred are of increasing complexity, as in Mary’s 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in mental health assessment following referral
Wider context from the report “1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been .
” Open source report
9 Sep 2021 Joshua SAHOTA · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure to communicate patient-specific restricted items to families and friends before ward visits View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joshua SAHOTA · 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
Joshua Sahota, a 25-year-old man, died on 9 September 2019 after being found with a plastic carrier bag over his head and a bed sheet around his neck while an inpatient on a mental health ward. The report raised concerns about ineffective communication to families and friends regarding items classified as restricted, including plastic carrier bags, and the inquest identified concerns including insufficient staffing, insufficient observations and one-to-one support, inadequate documentation, no psychologist availability, and an unclear restricted-items policy.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patient-specific restricted items to families and friends before ward visits
Wider context from the report “relate to the communication of what are ‘restricted and contraband items’ to the family and friends of a patient, before those family and friends visit the mental health ward.
This would be particularly important for a family or friends first visit to the ward.
The court was told that there are signs up at the entrance of the ward detailing items that are ‘contraband’. These items are not allowed onto the ward in any circumstances.
This makes it clear to all visitors what cannot be taken onto the ward in any circumstances.
However, the court was told that a ‘restricted item’ regime also exists, under which patients are risk assessed, with some being allowed particular items (such as mobile phone charger leads, laptop leads, belts and lighters), whilst others are not.
From the evidence we heard in this case, we know that Josh’s clothes were taken onto the ward in a plastic carrier bag, which at the time was a restricted item.
We heard that the bag was emptied, the contents were searched, re-packed and then taken to Josh’s room.
From the investigation into this matter, it is apparent that firstly, that had the family known that a plastic carrier bag was a restricted item, it would not have been taken to the hospital in the first instance.
Secondly, that had the family been aware that a plastic carrier bag was a restricted item, even though they may have used one to deliver Josh’s clothes, they would have drawn staff attention to the bag when it was subsequently taken and left in Josh’s room.
During the evidence no clear system or procedure was identified, for a family to be notified of any particular items that have been deemed ‘restricted’ items for their loved one to have in their possession.
There was therefore no effective communication with the family regarding what items were, and what items were not, allowed onto the ward in Josh’s case.
I am therefore concerned that families and friends of current in-patients, may still inadvertently take a particular item onto ward, or be aware that their loved one has a particular item in their possession, yet be totally unaware that that particular item has been risk assessed as a restricted item for their loved one.
It is known that families and friends of in-patients can play a vital role in their care, treatment and recovery. However, without knowing what have been deemed ‘restricted items’ for their loved one, the ability to assist in keeping their loved one safe whilst an in-patient, is effectively removed from those family and friends.
” 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 Improve visitor and service-user communications about the ban on plastic bags through updated letters, external messaging and ward signage.
Verbatim wording from the response “This item is a completely “banned” item across all inpatient units save our rehabilitation unit. Improvements have been made to our external messaging to families and carers on this subject plus a number of safeguards have been put in place to disrupt the passage of restricted items including plastic bags. For example on entering the main Wedgwood reception visitors are asked to show what items they have brought to the unit, if these are within or contain a plastic bag a paper one will be given as a replacement. Likewise for any service user going out on leave, on return they will be given an alternative type of bag either paper or canvas. When advancing to the ward reception there are posters and a “sandwich board” which highlight various pieces of information including restrictions on items coming in to the ward namely plastic bags.” Source location 2021-0301-Response-from-Hellesdon-Hospital_Published
Open published response
9 Aug 2021 Terence Robert TUTTLE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Lack of early mental health review View source Lack of early dietician assessment View source Inability to care for mentally unwell patients with physical health problems who are refusing to eat View source Failure to adequately assess under the Mental Capacity Act View source Failure to act on recorded weight loss View source Lack of recognition of serious harm View source Failure to include family members in care View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Robert TUTTLE · 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
Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of early mental health review
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of early dietician assessment
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to care for mentally unwell patients with physical health problems who are refusing to eat
Wider context from the report “4.Inability to care for a mentally unwell patient with physical health problems , including gastric problems, who is refusing to eat .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess under the Mental Capacity Act
Wider context from the report “3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recorded weight loss
Wider context from the report “2.Inaction when Mr Tuttle was losing weight even though his intake was recorded no-one acted upon this .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of serious harm
Wider context from the report “6. Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include family members in care
Wider context from the report “5.Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation.
” Open source report
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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 The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
Verbatim wording from the response “Out of the concerns listed below I would advise that NSFT are able to respond to the second part, in italics, of the first point only. The other points would be for the QEH to respond to:” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
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 Mental Health Liaison Teams do not provide direct hands-on physical interventions, including dietary advice or nutritional support.
Verbatim wording from the response “It may be helpful to outline the role of the Mental Health Liaison Teams within our acute general hospitals. The team are a triage assessment team and do not provide direct hands on care specifically in relation to physical interventions, for example dietary advice or nutritional balance activities. The team will advise on mental illness symptoms, diagnosis, compassionate least restrictive care and de-escalation techniques. The team will provide both nursing and medical input in relation to treatment including psychotropic medication and monitoring whilst the patient is on the acute ward. They may also arrange for transfer to a mental health ward once the patient is physically fit for discharge but requires further support in relation to their mental wellbeing.” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
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 For physical health decisions requiring capacity assessment, the physical health expert is the decision maker.
Verbatim wording from the response “Where a capacity assessment is required for a decision on a physical health issue or intervention, the team may assist in respect of mental illness symptomology and the potential impact on a persons capacity. However the decision maker will be the physical health expert.” Source location 2021-0265-Response-from-Hellesdon-Hospital_Published-1
Open published response
12 Dec 2019 Peter Frosdick · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Failure to offer or explore home treatment View source Failure to assess mental health beyond alcohol dependence View source Failure of teams to understand each other's referral criteria View source Failure to refer to Wellbeing Services View source Failure to exercise professional curiosity and consider GP information View source Failure to offer hospital admission when indicated View source Failure to accept patients whose mental state does not fit a psychiatric label View source See 4 more concerns
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
Peter Frosdick · 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
Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to offer or explore home treatment
Wider context from the report “(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored . His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess mental health beyond alcohol dependence
Wider context from the report “(1) That no-one appeared to have looked at his mental health except to note that he was alcohol dependant . This was an escalating presentation from someone who had no previous contact with the services.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of teams to understand each other's referral criteria
Wider context from the report “(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer to Wellbeing Services
Wider context from the report “(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to exercise professional curiosity and consider GP information
Wider context from the report “(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to offer hospital admission when indicated
Wider context from the report “(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accept patients whose mental state does not fit a psychiatric label
Wider context from the report “(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on . When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't.
” Open source report
17 Sep 2019 Tyla Katherine Joan COOK · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to organise a multi-disciplinary learning event on emergency non-technical skills View source Failure to maintain up-to-date written care and crisis plans View source Delays in Eating Disorder Service assessment due to caseload capacity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tyla Katherine Joan COOK · 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
Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to organise a multi-disciplinary learning event on emergency non-technical skills
Wider context from the report “3. The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non-technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event . The Care providers indicated it was the West Norfolk Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group Review was published 8 May 2019. No steps have been taken with regard to this learning event , save East of England Ambulance Service Trust has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date written care and crisis plans
Wider context from the report “2. There was no written up-to-date care and crisis plans in place . The most recent written care plan related to Tyla being an inpatient at the Dragonfly Unit, from where he was discharged on 9 August 2017. The written plans were therefore several months out of date . This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further 3 months was requested to prepare an up to date written care plan. In the event, and despite the family’s repeated requests for plans in writing, it was decided the care plan could be commenced by 30 November 2017, on the basis Tyla’s input into the Care Plan was important and it would take time to gain his meaningful input. The evidence was that there were oral plans in place which were relayed to the parents (including at times of distress), who continued to request plans in writing. The high level of distress and anxiety within Tyla’s home was recognised. An interim written plan was not considered nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken by the Trust to recognise when up to date written plans are not in place and it is understood staff have undergone some work in improving the quality of care plans. However in this case an active decision was made not to update the written plan for some time . Further the evidence did not reveal any insight into the support a written plan could have given the family to support Tyla.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in Eating Disorder Service assessment due to caseload capacity
Wider context from the report “1. It was agreed at the CETR meeting on 9 August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017 . The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla ;
” 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 Provide interim and updated written care and crisis plans, including emergency contacts and safety plans after unplanned discharge, with reviews within seven and 28 days.
Verbatim wording from the response “Trust response to concern 2:
NSFT recognises the importance of care plans for all service users and that these need to be done in collaboration with the service user and their families / carers if possible. However, in some circumstances this can take time in which case an interim care plan will be put in place whilst a more comprehensive and collaborative plan is being developed.” Source location 2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Roll out staff training in care planning and crisis or safety planning to embed the revised care-planning processes.
Verbatim wording from the response “A programme of training being rolled out offers training in care planning and crisis or safety planning with all staff which will ensure the above changes are embedded within teams.” Source location 2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Attend a fixed multi-agency meeting with partner organisations to plan the recommended non-technical-skills learning event.
Verbatim wording from the response “Trust response to concern 3:
There is a multi-agency meeting fixed for the 4th November which our Head of Patient Safety, Saranna Burgess, will attend with representatives from all the other organisations involved to plan this.” Source location 2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Implement cross-team joint working, risk-prioritised access, escalation of capacity concerns, and coordinated reviews for service users with complex co-morbid conditions.
Verbatim wording from the response “Trust response to concern 1:
In order to prevent delays accessing care when a service user presents with complex co-morbid mental health conditions the following process has been developed.” Source location 2019-0299-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
25 Apr 2019 Kerry Hunter · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure of the BPD service access pathway to provide treatment without requiring transfer to an Integrated Delivery Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kerry Hunter · 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
Kerry Hunter died in hospital on 1 May 2016 after administering an overdose of insulin to herself and subsequently deteriorating. She had Borderline Personality Disorder and a history of suicide attempts; although Dialectical Behavioural Therapy was available and she was considered a suitable candidate, it was not provided because this was not recognised at the time. The principal concern was that a proposed requirement for patients to transfer to an Integrated Delivery Team before accessing the new service might prevent some people with Borderline Personality Disorder from receiving needed treatment.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the BPD service access pathway to provide treatment without requiring transfer to an Integrated Delivery Team
Wider context from the report “Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder Service, those suffering from the condition would have to agree to be transferred for treatment under the Norfolk and Suffolk Foundation Trust Integrated Delivery Team for onward referral to the new bespoke service .
However, ████████ explained that the majority of individuals with a diagnosis with BPD will have had significant previous contact with their mental health service providers .
Kerry herself, had had significant history of previous treatments over a number of years (including Cognitive Behavioural Therapy, Cognitive Analytical Therapy, anti-depression medication and anti-psychotic medication), none of which had proved effective.
████████ confirmed that none of these treatments would have been likely to have had a positive therapeutic effect, which in itself would compound the nature of BPD itself.
████████ explained that the cycle of being offered ineffective treatment would enhance the loss of hope and optimism which is a feature of BPD. Another facet of BPD was an avoidant personality making sufferers unwilling or unable to engage with new individuals or teams .
This being the case, I am concerned that the proposed requirement in the Norfolk and Suffolk Foundation Trust plan (which will require a BPD suffer to agree to a transfer to an Integrated Delivery Team before being placed onto the new service) may prevent some patients gaining the access to the treatment they clearly need .
” 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 Conduct regular reviews of service outcomes and access routes during implementation to inform service adjustments.
Verbatim wording from the response “As we implement the service we will have regular review points to assess the impact both in terms of outcomes but also in respect of areas such as the access route. This will help inform adjustments in order to provide an effective service.” Source location 2019-0137-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Introduce needs-based screening and assessment to direct people to appropriate treatment and prevent unnecessary hospital admissions.
Verbatim wording from the response “The plan for the new Personality Disorder Service involves eight elements:” Source location 2019-0137-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Increase community-team staffing and capability so service users can access evidence-based treatment without specialist-service referral or care transitions.
Verbatim wording from the response “Concern around stepping up and down: In the PFD in relation to Kerry Hunter, it was stated that “those with BPD would have to agree to be transferred for treatment from the Integrated Delivery Team to the new service and it was noted by the expert witness, ████████ that many service users will have had significant previous contact with mental health services”.
We have upskilled and increased the staffing resource within community teams so that service users now have improved to access evidence-based treatment. This means that service users do not have to be referred on to a specialist service or face transitions of care in order to access specialist treatment. Where teams have not been able to support a full programme of an evidence-based therapy (like DBT), there are partial programmes in place.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Support primary-care mental health practitioners to provide evidence-informed approaches and expand psychological therapy availability.
Verbatim wording from the response “Within primary care, we are supporting our Mental Health Practitioners (MHPs) to offer evidence-informed approaches, and we are working to expand the availability of psychological therapy to close the gap between primary and secondary care. We recognise that transitions of care can be difficult for our service users, and seek to have a “no wrong door” approach across the system, so that service users can access the right care, wherever they initially present.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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 Service users can access specialist evidence-based treatment in community teams without referral to specialist services or transitions of care.
Verbatim wording from the response “Concern around stepping up and down: In the PFD in relation to Kerry Hunter, it was stated that “those with BPD would have to agree to be transferred for treatment from the Integrated Delivery Team to the new service and it was noted by the expert witness, ████████ that many service users will have had significant previous contact with mental health services”.
We have upskilled and increased the staffing resource within community teams so that service users now have improved to access evidence-based treatment. This means that service users do not have to be referred on to a specialist service or face transitions of care in order to access specialist treatment. Where teams have not been able to support a full programme of an evidence-based therapy (like DBT), there are partial programmes in place.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
15 Apr 2019 Nyall Cye BROWN · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to consider the care-record review concern in investigation View source Failure to review previous care records before assessing a service user View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nyall Cye BROWN · 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
Nyall Cye Brown was found hanging in woodland on 17 May 2018 and died in hospital on 22 May 2018. Concerns included that his care records were not reviewed before he was assessed, meaning his full history and risks could not be taken into account, and that this issue had been raised previously but was not always addressed. The issue was also not considered in the Trust’s 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the care-record review concern in investigation
Wider context from the report “1. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him.
2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening.
3. This matter was not considered in the otherwise thorough investigation conducted by the Trust .
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review previous care records before assessing a service user
Wider context from the report “1. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen , which would enable Mr Brown’s full history and risks to be taken into account when assessing him.
2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening .
3. This matter was not considered in the otherwise thorough investigation conducted by the Trust.
” 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 Introduce Patient Participation Leads and new Clinical Directors to strengthen clinical and service leadership and oversee learning from serious incidents.
Verbatim wording from the response “To positively influence the Trust’s improvement work we are strengthening the clinical and service leadership in order to ensure there is the necessary breadth of skills and resource to lead safe and effective services. Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience. The Trust has recruited to the majority of these roles which will be fully effective from September 2019. A key function of this new approach will be the accountability to share learning, implement and monitor recommendations from serious incidents.” Source location 2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Deliver a learning session on record keeping, communication and preparation before appointments.
Verbatim wording from the response “The Trust has commissioned a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager commencing in June 2019. Alongside a focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication, the session will include content related to the importance of preparation ahead of appointments.” Source location 2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
9 Apr 2019 Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 5 Failure to involve the practice nurse in care View source Failure to provide daily visits from the mental health team View source Failure to involve the next of kin in care View source Failure to undertake a formal mental health act assessment View source Failure to use the Corner house care facility when indicated View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Hayward BUCKINGHAM · 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
Anthony Hayward BUCKINGHAM died at home on 13 March 2018 with a metal cable around his neck, after a previous suicide attempt and ongoing suicidal thoughts. The inquest highlighted concerns about the frequency of mental health visits, involvement of his father and practice nurse, a formal mental health assessment, and use of a care facility.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the practice nurse in care
Wider context from the report “At the Inquest it was highlighted the following could have been done to try and prevent his death
1/ Daily visits from the mental health team
2/ Involvement of the next of kin (his father)
3/ Formal mental health act assessment
4/ Involvement of the practice nurse
5/ Use of Corner house care facility
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide daily visits from the mental health team
Wider context from the report “At the Inquest it was highlighted the following could have been done to try and prevent his death
1/ Daily visits from the mental health team
2/ Involvement of the next of kin (his father)
3/ Formal mental health act assessment
4/ Involvement of the practice nurse
5/ Use of Corner house care facility
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the next of kin in care
Wider context from the report “At the Inquest it was highlighted the following could have been done to try and prevent his death
1/ Daily visits from the mental health team
2/ Involvement of the next of kin (his father)
3/ Formal mental health act assessment
4/ Involvement of the practice nurse
5/ Use of Corner house care facility
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a formal mental health act assessment
Wider context from the report “At the Inquest it was highlighted the following could have been done to try and prevent his death
1/ Daily visits from the mental health team
2/ Involvement of the next of kin (his father)
3/ Formal mental health act assessment
4/ Involvement of the practice nurse
5/ Use of Corner house care facility
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the Corner house care facility when indicated
Wider context from the report “At the Inquest it was highlighted the following could have been done to try and prevent his death
1/ Daily visits from the mental health team
2/ Involvement of the next of kin (his father)
3/ Formal mental health act assessment
4/ Involvement of the practice nurse
5/ Use of Corner house care facility
” 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 Allocate a responsible staff member for each service user to coordinate comprehensive care packages and engagement with other agencies.
Verbatim wording from the response “The Trust's internal investigation identified learning regarding the need to liaise and work with other agencies involved in the care of the service user. The team's current working process is to allocate an individual staff member to each service user; they have some additional responsibilities to ensure the care package is comprehensive and includes all other agencies. In addition, the multi-disciplinary team meetings help identify key others involved in care and allocate action of who will engage them.” Source location 2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Evaluate next-of-kin processes, require corrective action, and monitor improvement through audit and quality and safety reviews.
Verbatim wording from the response “The Trust's internal investigation confirmed that the next of kin details were not obtained from Anthony, thereby impacting on their ability to engage his family. This was not picked up during the period of contact with the Home Treatment Team. A recommendation of work was made by the internal investigation resulting in the care team evaluating their processes. The clinical team leader monitors this taking action where required. The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews.” Source location 2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 staff allocation and multidisciplinary meetings identify and coordinate other agencies involved in a service user's care, including practice nurses.
Verbatim wording from the response “The Trust's internal investigation identified learning regarding the need to liaise and work with other agencies involved in the care of the service user. The team's current working process is to allocate an individual staff member to each service user; they have some additional responsibilities to ensure the care package is comprehensive and includes all other agencies. In addition, the multi-disciplinary team meetings help identify key others involved in care and allocate action of who will engage them.” Source location 2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 The response does not identify a stage requiring mental health legislation assessment; engagement with offered care supported least restrictive treatment.
Verbatim wording from the response “The report doesn't identify at which stage of care a request for a mental health act assessment may have been appropriate. Following the initial assessment, Anthony was an assessment and was engaged with the appointments and telephone calls offered. This was in keeping with the principle of least restrictive treatment.” Source location 2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Use of Corner House is not treated as necessary because support is individually assessed and multiple statutory and non-statutory options are available.
Verbatim wording from the response “It is critical that Trust services engage with other agencies to ensure there are comprehensive packages of care in place for our service users and carers. Such support needs are individual based on assessment. The range of statutory and non-statutory support that is available is significant and ever evolving. Thinking of this wider partner network and the requirement for close working, our suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. These events of introduction have been well received leading to the building and strengthening of networks. We have more planned for all areas of the Trust over the coming months.” Source location 2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Contact frequency is determined flexibly by multidisciplinary assessment and service-user needs, rather than requiring daily mental health team visits.
Verbatim wording from the response “The Trust's internal investigation identified that Anthony had no contact with mental health services prior to February 2018. Following referral to the Trust he was provided with support by the Home Treatment Team. This team provides short term support for people experiencing acute mental health needs, through visits and telephone calls. From the period 16 February 2018 to 13 March 2018 the team completed seven face to face contacts and seven telephone contacts. The decision as to the frequency of contact is considered by the multi-disciplinary team in conjunction with the service user, based on their presenting needs. The multi-disciplinary team approach assists to ensure all perspectives are considered and the judgement is a shared decision. Through this process contact can be increased and decreased on a flexible basis.” Source location 2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
6 Apr 2019 Darren Edward KING · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Lack of effective follow-up action when high-risk patients with learning disabilities disengage View source Lack of a clear escalation process for increased risks that cannot be easily addressed View source Lack of a structured medication review within the overall Care Plan Approach View source
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
Darren Edward KING · 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
Darren King died at home after an epileptic seizure while in the bath, with drowning recorded as the medical cause of death. The report identified concerns about inadequate follow-up when a high-risk patient with learning disabilities disengages, the lack of a clear escalation process, and the absence of a structured medication review within the care plan.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective follow-up action when high-risk patients with learning disabilities disengage
Wider context from the report “1. The lack of effective follow up action when a patient with learning disabilities disengages , especially when they are a high-risk patient (such as Darren).
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear escalation process for increased risks that cannot be easily addressed
Wider context from the report “2. The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed (as it was in Darren’s 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a structured medication review within the overall Care Plan Approach
Wider context from the report “3. The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern.
” Open source report
18 Mar 2019 Ellie Jane LONG · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to maintain timely disclosure of all relevant documents View source Failure to sustain the priority of record keeping and disclosure requirements View source Failure to maintain full and contemporaneous electronic records View source Failure to share relevant information and communicate with external agencies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ellie Jane LONG · 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
Ellie Long was receiving community treatment from the Eating Disorder Service and had diagnoses of Anorexia Nervosa and Depression. She was found hanging in her bedroom on 10 December 2017 and died in hospital on 12 December 2017. The principal concerns were incomplete record keeping and disclosure, and inadequate communication and information sharing with external agencies including her GP and school.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain timely disclosure of all relevant documents
Wider context from the report “1. Record keeping and Auditing of Record keeping
a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences . This avoids potential delay in the inquest process and further distress to the family.
b) Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved.
c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk”. Further, record keeping has been raised elsewhere as a matter of concern within NSFT.
d) I have concern that full record keeping and disclosure requirements will not remain a priority.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to sustain the priority of record keeping and disclosure requirements
Wider context from the report “1. Record keeping and Auditing of Record keeping
a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family.
b) Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved.
c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk”. Further, record keeping has been raised elsewhere as a matter of concern within NSFT.
d) I have concern that full record keeping and disclosure requirements will not remain a priority.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain full and contemporaneous electronic records
Wider context from the report “1. Record keeping and Auditing of Record keeping
a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records . Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family.
b) Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved.
c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk”. Further, record keeping has been raised elsewhere as a matter of concern within NSFT.
d) I have concern that full record keeping and disclosure requirements will not remain a priority.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information and communicate with external agencies
Wider context from the report “2. Communication with External Agencies
a) An initial full, updating letter was sent to Ellie’s GP. However no further updating information was sent. A letter was written providing updating information, but this was not sent. No further updating information was sent to the GP by telephone, letter or email.
b) The evidence heard is that efforts were made to contact the school by telephone. However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school.
c) It is accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will “remind staff of the importance of recording efforts to share information/maintain communication”.
d) Sharing of information and communication with external agencies is a matter which has been raised with NSFT on previous occasions. The importance of “recording efforts to share information ...” may not be sufficient to prevent future deaths. It is the importance of sharing information and communicating with external agencies that should be addressed here. Recording of information is dealt with at Point 1 above.
” 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 Instruct all clinical services to review record-keeping and partner-agency communication practices.
Verbatim wording from the response “All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.” Source location 2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Provide management assurance on actions taken to improve record keeping and partner-agency communication.
Verbatim wording from the response “All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.” Source location 2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Deliver a learning session on clinicians’ regulatory, legal and professional responsibilities for record keeping and communication.
Verbatim wording from the response “Supporting this is a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. The session will have a specific focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication.” Source location 2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Monitor intervention effectiveness through audit, user feedback and quality and safety reviews.
Verbatim wording from the response “The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement.” Source location 2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Review working practices for record keeping and communication with partner agencies across clinical services.
Verbatim wording from the response “All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.” Source location 2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Operational managers are responsible for reviewing record-keeping and partner-agency communication practices and providing assurance of improvement actions.
Verbatim wording from the response “All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.” Source location 2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
13 Mar 2019 Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to provide continuity in the number of staff involved in care View source Failure to assign definitive, timed actions and named responsibility for identified care concerns View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tamsin Rebecca Lianne GRUNDY · 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
Tamsin Rebecca Lianne Grundy, who had a history of depression and was under the care of Mental Health Services, was found dead at home on 26 July 2018 with a weightlifting bar across her neck. Concerns included her difficulty relating to the more than 25 members of the Crisis Resolution Home Treatment Team involved in her care and the lack of a definitive, timed action or named person responsible for addressing this issue.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuity in the number of staff involved in care
Wider context from the report “1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team . It is understood Miss Grundy saw 25 plus members of the Team in some 14 months . The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service .
2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign definitive, timed actions and named responsibility for identified care concerns
Wider context from the report “1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team. It is understood Miss Grundy saw 25 plus members of the Team in some 14 months. The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service.
2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action .
” Open source report
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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 Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.
Verbatim wording from the response “Notwithstanding this challenge, it was the expressed experience of Ms Grundy that having such numbers of staff involved made it difficult to form therapeutic relationships. To support continued development of the service provided, the CRHT team is using a national 39 point fidelity scale to help it reflect on current practices identifying areas of focus and improvement. One of the points refers directly to this matter and the team are working to apply this on a consistent basis, using daily planning to match clinicians with individual visits where a positive therapeutic relationship has developed. The scale is being used more widely across the Trust.” Source location 2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
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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 The CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.
Verbatim wording from the response “Ms Grundy was in contact with the Trust’s Youth Service since 2016. She was allocated a staff member whose role was to coordinate her care. This member played an important role in forming a therapeutic relationship with the service user, working together to implement plans to help respond to the individual’s needs. There are occasions where an individual’s need changes requiring a period of more intensive support which is provided by the Trust’s acute services. The CRHT provide intensive periods of support in the community for short periods, supplementing the care provided by the community team. This means the team have to be flexible and adaptable in approach requiring staff to work over a 24 hour period, seven days per week. Appointments with users may range from multiple contacts in a day to every few days.” Source location 2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
19 Dec 2018 Henry Curtis-Williams · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Failure to record contemporaneous clinical notes, including presence or absence of suicidal ideation View source Failure to require senior clinical reference before discharge by very junior doctors View source Failure to formally record and communicate important messages between staff members View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Henry Curtis-Williams · 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
Henry Curtis-Williams died from hanging at Acton Cemetery on 17 May 2018; the inquest conclusion was hanging and suicide. Concerns included inadequate contemporaneous recording, discharge by junior doctors without prior senior review, and informal communication without records of important messages.
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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record contemporaneous clinical notes, including presence or absence of suicidal ideation
Wider context from the report “(1) That following admission to Southgate Ward Henry Curtis-Williams was seen by a number of different staff members. It became evident that there was a culture of not recording contemporaneous notes. This was very obvious with reference to recording presence or absence of suicidal ideation.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require senior clinical reference before discharge by very junior doctors
Wider context from the report “(2) There was an acceptance that patients could be discharged by very junior doctors without prior reference to Consultant or Senior colleagues even though Henry had been admitted after being assessed by 2 Section 12 approved doctors and an Appointed Mental Health Professional who felt he needed a prolonged inpatient stay.
” 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 Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record and communicate important messages between staff members
Wider context from the report “(3) Communication between staff members was very informal with no record kept of important messages relayed. For example, the member of staff who held a one to one meeting with Henry was not present at the ward round where Henry’s case was discussed but said she had verbally passed a message to the ward round nurse. This was normal practice on this ward. There was no record of the message, or of it being passed or that it was considered at the ward round.
” Open source report
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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 Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.
Verbatim wording from the response “You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has” Source location 2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
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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 Issue an internal alert directing inpatient wards to reflect on how information from different sources is received and captured.
Verbatim wording from the response “There is no current single evidence-based tool which can be implemented to eliminate this potential. However, shared understanding amongst staff of the processes of receiving information is critical to reduce variance. Following some recent learning, the Trust has issued an internal alert to all inpatient wards directing reflection on the points where information is received from differing sources eg service users, families and carers and whether there is a shared process or understanding of how to ensure that information is captured. Where there may not be a shared understanding the ward will work to address this. Feedback from this alert is being received currently which will then be shared across the wards to promote wider learning.” Source location 2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
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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 Provide learning to Consultant Psychiatrists about senior involvement in discharge decisions.
Verbatim wording from the response “You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has” Source location 2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
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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 Provide junior doctors with discharge-related teaching during Trust induction.
Verbatim wording from the response “provided learning to Consultant Psychiatrists and teaching will be provided to junior doctors as part of their induction to the Trust.” Source location 2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
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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 No single evidence-based communication tool can currently be implemented to eliminate the risk of important information failing to reach ward rounds.
Verbatim wording from the response “There is no current single evidence-based tool which can be implemented to eliminate this potential. However, shared understanding amongst staff of the processes of receiving information is critical to reduce variance. Following some recent learning, the Trust has issued an internal alert to all inpatient wards directing reflection on the points where information is received from differing sources eg service users, families and carers and whether there is a shared process or understanding of how to ensure that information is captured. Where there may not be a shared understanding the ward will work to address this. Feedback from this alert is being received currently which will then be shared across the wards to promote wider learning.” Source location 2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations