27 Feb 2018 Rachel Holly Edwards · Prevention of Future Deaths report Suffolk
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Concerns raised 4 Failure to reliably notify GPs of discharge medication types and quantities View source Failure to prescribe safe quantities of discharge medication for patients at risk of stockpiling medication View source Failure to record the quantities of discharge medication issued View source Lack of a formal patient advocate system for patients needing support with distressing treatment news and complex care arrangements View source See 1 more concern
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Rachel Holly Edwards · 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
Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.
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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 reliably notify GPs of discharge medication types and quantities
Wider context from the report “The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping.
It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned.
Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk.
It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’.
That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period.
However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts.
Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern.
Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’ .
” 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 prescribe safe quantities of discharge medication for patients at risk of stockpiling medication
Wider context from the report “The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping.
It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned.
Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk.
It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’.
That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period.
However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts.
Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern.
Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’.
” 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 the quantities of discharge medication issued
Wider context from the report “The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping.
It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned.
Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk.
It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’.
That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period.
However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts.
Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern.
Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’.
” 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 formal patient advocate system for patients needing support with distressing treatment news and complex care arrangements
Wider context from the report “Secondly, it was a known that the arrival of disappointing news regarding her pain management treatment was a clear stressor to Rachel and that such news significantly increased her sense of hopelessness.
Despite this being known there was no ‘patient advocate’ or other similar service in place to act as filter and alert those providing support to prepare for the increased feeling of hopelessness that would clearly follow such news.
Further, dealing with the large quantity of correspondence generated by her various treatment regimes and trying to de-conflict and re-schedule multiple appointments also left Rachel feeling overwhelmed, again adding to her sense of hopelessness. Again, no effective patient advocate system was in place to support her with this.
During the inquest an example of the good use of a ‘patient advocate’ scheme was heard, but this advocate was in place by virtue of the initiative of a local mental health practitioner. As such it was identified that although a ‘patient advocate’ could provide the support needed when appropriate, there is no formal system in place for an advocate to be appointed in other cases when it could prove beneficial.
” 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 Assess medications prescribed on discharge across the Trust.
Verbatim wording from the response “The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust. In the majority of situations an individual’s recovery into the community is supported by a period of care with the Crisis Resolution and Home Treatment team.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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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 Register the advocacy matter with commissioners.
Verbatim wording from the response “Your third point raised the matter that Ms Edwards’ situation was heavily influenced by the physical pain she experienced. She received disappointing news regarding her pain management treatment, increasing her sense of hopelessness. You heard evidence that she did not have an advocate to support her. You stated that advocacy services provide support to people in need and that we should consider establishing a formal system for an advocate to be appointed, where this may be beneficial.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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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 Plan the technical changes required to notify GPs electronically about prescribed discharge medication.
Verbatim wording from the response “You raised the matter that there was no automated notification to the service user’s GP of the type and amounts of prescribed medication issued at the point of discharge. This information is crucial to help reduce the potential of over prescribing. You heard that the current process involves human action through use of emails.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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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 Commissioners, rather than the Trust, are responsible for commissioning advocacy services; access otherwise depends on consent or statutory frameworks.
Verbatim wording from the response “The Trust supports the significant and valuable role that advocacy services provide. The Trust is established in working with advocacy services as part of statutory frameworks, such as the Mental Health Act, Mental Capacity Act and complaints regulations. Equally, the Trust works with advocacy services where this has been requested by the service user to support the best possible forms of communication and collaboration. Such services are not commissioned by the Trust and the process to access such are either through service user consent or under the guidance of the above named frameworks. The Trust will register this matter with its commissioners.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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8 Dec 2017 BENJAMIN THOMAS GOODRUM · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Failure to allocate a specific individual Care Co-Ordinator or Lead Care Professional to service users receiving active treatment 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
BENJAMIN THOMAS GOODRUM · 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
Benjamin Thomas Goodrum, who had schizophrenia and Asperger’s syndrome and lived in the community with support from several organisations and his parents, was found clearly deceased in his flat on 27 June 2016. Concerns included the absence of a person with overall responsibility for him, the failure to appoint a replacement Care Co-Ordinator, and the incomplete implementation of an investigation recommendation concerning allocation of a Lead Care Professional or Care Co-Ordinator.
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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 a specific individual Care Co-Ordinator or Lead Care Professional to service users receiving active treatment
Wider context from the report “(1) Although there was evidence of good communication between the various organisations involved with Mr Goodrum and attempts were ongoing to retain contact with him, there was no person taking overall responsibility for Mr Goodrum .
(2) Mr Goodrum had originally been allocated a Care Co-Ordinator but on this person leaving, no new Care Co-Ordinator was appointed .
(3) The Serious Incident Investigation recommended all service users receiving active treatment should be allocated a Lead Care Professional or a Care Co-Ordinator and this action was to be completed by 30/04/2017. At the time of the inquest this action had not been put in place and the Action Plan was regarded as complete.
(4) Evidence was heard that alternative measures have been taken within the various teams to ameliorate the lack of sufficient Care Co-Ordinators for service users , for instance using a team-based approach, but that such measures are not as effective as services having a specific individual appointed as a Care Co-Ordinator .
” Open source report
14 Nov 2017 BRIAN STANNARD · Prevention of Future Deaths report Norfolk
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Concerns raised 5 Failure to provide adequately trained and equipped staff for people with coexisting mental and physical ill-health View source Failure to complete staff records fully during the same shift View source Workload-related delays in staff record completion View source Failure of all staff to use the Lorenzo computer system to its full potential View source Failure of the Lorenzo computer system to be fully operational View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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BRIAN STANNARD · 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
Brian Stannard was a resident at Eversley Nursing Home and was found drowned on a beach at Great Yarmouth on 14 November 2016 after being seen asleep in his room earlier that morning. The report raised concerns about the nursing home’s capacity to manage his mental ill health and threats of self-harm or suicide, as well as incomplete staff records and limited use of the Lorenzo computer system.
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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 provide adequately trained and equipped staff for people with coexisting mental and physical ill-health
Wider context from the report “(1) Mr Stannard had mental ill health and physical ill health. He was placed at a Nursing Home to manage his physical ill health as this was seen as the priority at the time of admission. Staff at the Home were not adequately equipped to deal with his mental ill health as his physical health improved. This not only raises concern with regard to the safety and well-being of the individual concerned, but also with regard to the staff involved in Mr Stannard’s care. They were not trained mental health individuals and were required to deal with attempts at and threats of self-harm and suicide by Mr Stannard. There did not appear to be a Home available where staff were adequately trained to deal with a person’s mental and physical ill-health.
” 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 complete staff records fully during the same shift
Wider context from the report “(2) Records of staff were not always completed or fully completed. Staff are now provided with laptops to aid flexibility with regard to record keeping. It is understood staff are now required to complete their records by the end of each shift. Due to the volume of work, it is not clear if members of staff are given sufficient time and space to see the service user and then to write up their records during the same shift.
” 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 Workload-related delays in staff record completion
Wider context from the report “(3) Due to volume of work, some staff may be completing their records in their own time.
” 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 all staff to use the Lorenzo computer system to its full potential
Wider context from the report “(4) The Lorenzo computer system was brought in some years ago. It does not appear to be fully operational and used to its full potential by 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 Failure of the Lorenzo computer system to be fully operational
Wider context from the report “(4) The Lorenzo computer system was brought in some years ago. It does not appear to be fully operational and used to its full potential by all staff.
” 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 Provide site visits from business-change and training specialists to develop staff use of the Lorenzo system.
Verbatim wording from the response “The system is fully operational, however the Trust is aware and is addressing some issues with it. Staff are currently receiving site visits from business change and training specialists to continue to develop their use of the system and the Trust is working with the system suppliers to improve its performance and usability.” Source location 2017-0394-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 Improve health-record completion through an organisation-wide programme with active monitoring.
Verbatim wording from the response “Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a program to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way.” Source location 2017-0394-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 Work with clinical teams to provide sufficient staffing and equipment for consistent, balanced work allocation.
Verbatim wording from the response “Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a program to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way.” Source location 2017-0394-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 Implement the Lorenzo electronic patient-record system across the Trust to replace paper records and consolidate electronic systems.
Verbatim wording from the response “The Lorenzo computer system was implemented across the Trust in May 2015, replacing paper records and, in some areas, consolidating separate electronic systems into one. This has improved clinical safety by providing access to clinical information regardless of location and improving communications between different teams caring for the same patient.” Source location 2017-0394-Response
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 Work with Lorenzo system suppliers to improve system performance and usability.
Verbatim wording from the response “The system is fully operational, however the Trust is aware and is addressing some issues with it. Staff are currently receiving site visits from business change and training specialists to continue to develop their use of the system and the Trust is working with the system suppliers to improve its performance and usability.” Source location 2017-0394-Response
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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 Providing accommodation supporting individuals with complex and fluctuating needs is outside the Trust’s direct control.
Verbatim wording from the response “You raise an important issue regarding the provision of a range of accommodation services that can support individuals with complex and fluctuating needs. Such provision of accommodation is outside of the direct control of the Trust. The Trust’s role is to continually monitor the service user’s presentation and to help facilitate changes where these are required. For Mr Stannard, this would have involved working with him, his family, the care home, continuing healthcare services and the GP. The Trust’s Root Cause Analysis (RCA) investigation identified there was evidence of inter-agency working noting a routine review meeting was held on 7 November 2016. This meeting observed Mr Stannard’s continued physical and mental health presentation, identifying plans to assist with his benefit entitlement and to seek advocacy support to assist with decisions about potential future physical events.” Source location 2017-0394-Response
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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 Lorenzo electronic patient record system is fully operational, although the Trust is addressing some issues with it.
Verbatim wording from the response “Your report noted the Lorenzo electronic patient record system was introduced some years ago but that it does not appear to be fully operational and used to its full potential by all staff. The report does not detail the specific areas of concern.” Source location 2017-0394-Response
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8 Feb 2017 DAVID SEAN READ · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Delays in arranging a fresh Community Mental Health Team appointment after cancellation of an initial appointment View source
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DAVID SEAN READ · 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
David Sean Read collapsed after injecting heroin on 1 July 2016 and died in hospital on 3 July 2016. Concerns were raised about the handling and timing of his Community Mental Health Team appointments, including that a replacement appointment was scheduled more than 16 weeks after re-referral, during which time he died.
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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 Delays in arranging a fresh Community Mental Health Team appointment after cancellation of an initial appointment
Wider context from the report “(3) This appointment was cancelled by Mr Read (no reason is recorded for the cancellation but Mr Read did start alcohol detoxification on this date) and his name was added to the waiting list for a fresh appointment to be arranged .
(4) The appointment was treated as a new referral and a new appointment date was sent out on the 18 May 2016 with a new appointment date of 14 July 2016 . This is in excess of 16 weeks after the re-referral . Sadly Mr Read died in the meantime.
” 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 Complete recruitment to vacancies so the community mental health team is fully staffed.
Verbatim wording from the response “Reflecting on this period of time, it is observed there were a number of challenges within the team with respect to vacancies and staff on maternity leave. These had an impact on the team’s ability to offer appointments. Subsequent to this period, recruitment to vacancies means the team is currently fully staffed.” Source location 2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Trust
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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 Have the clinical team leader review pending appointments daily and allocate earlier appointments according to assessed changes in risk.
Verbatim wording from the response “- The clinical team leader monitors cases that have an appointment pending on a daily basis, taking account of any phone calls or concerns and allocates them a sooner appointment based on the assessment of potential change in risk.” Source location 2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Trust
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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 Telephone service users who miss appointments to rearrange them instead of sending letters.
Verbatim wording from the response “- If a service user does not attend an appointment they will have a phone call to rearrange an appointment instead of sending a letter.
- The service user will no longer get a letter stating that they have been put on a waiting list.
- The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending the appointment they can speak to someone.
- Any phone calls to the team or duty worker raising concerns are documented on Lorenzo (the electronic patient record system) and communicated within the team.” Source location 2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
24 Dec 2015 CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report Norfolk
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Concerns raised 5 Failure to risk assess and make safe the physical environment before patient access View source Failure of staff to understand required patient-observation practices View source Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E View source Failure to record information gained from patient observations correctly View source Failure of escort policy and planning to address inter-service patient transfers View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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CHRISTOPHER JONATHAN HIGGINS · 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 Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.
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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 risk assess and make safe the physical environment before patient access
Wider context from the report “(3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette . It is understood that since Mr Higgins' death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death . Other ways of making the area safe are still under consideration .
” 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 understand required patient-observation practices
Wider context from the report “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient . This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation.
” 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 an agreed pathway for detained patients requiring assessment and treatment at A & E
Wider context from the report “(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E , as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area , having already self-harmed and shown signs of paranoia.
” 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 information gained from patient observations correctly
Wider context from the report “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation .
” 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 escort policy and planning to address inter-service patient transfers
Wider context from the report “(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police . In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him . The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins;
” 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 Strengthen policy direction so staff accompany patients during transfers wherever possible, with safety-based decisions made with other involved services.
Verbatim wording from the response “Your report reflected the fact that Mr Higgins was transferred in the Police van back to the Fermoy Unit without a member of mental health staff present. Accepting that in Mr Higgins’s case the travel time and distance was small (within the site), the Trust acknowledges how important this can be for the patient. Therefore the Trust will be strengthening its policy direction (the policy is further” Source location 2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
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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 local protocols with acute-hospital colleagues for timely, least-distressing assessment of patients with mental health needs and incorporate them into policy.
Verbatim wording from the response “In addition to writing to the Trust, you have communicated with the local acute hospitals in Norfolk with the intention of raising to both services the consideration of how patients with mental health needs are cared for in a timely and least distressing way.” Source location 2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
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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 Communicate updated observation requirements through staff emails, the Patient Safety Newsletter, and governance and leadership forums.
Verbatim wording from the response “Amending policy is one action, which must be followed by communication to ensure its adoption by all staff. The Trust uses a range of communications including updates by email, within a Patient Safety Newsletter and discussion at governance and leadership forums. Through this range of means, staff are updated of the requirement to adapt practice.” Source location 2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
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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 Fully enclose the ramp to remove the possibility of an individual jumping from its top area.
Verbatim wording from the response “Following the inquest the Trust has revisited the assessment of this area. Whilst there are mitigations in place such as the heightened rail and access to the area by patients is made with supervision, the Trust has decided to fully enclose the ramp. This work has commenced and is proposed to be completed by the end of March 2016 and removes the possibility of an individual jumping from the top of the ramp area.” Source location 2015-0480-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 Add additional height bars to the disabled-access ramp railing to reduce the likelihood of people jumping over it.
Verbatim wording from the response “Following the incident the Trust reviewed the railing that sits with the disabled access ramp, adding additional height bars to reduce the likelihood that an individual could, from a standing position, jump over the top of them.” Source location 2015-0480-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 and update the Observation and Engagement of Service Users policy to clarify additional-observation requirements.
Verbatim wording from the response “Your report identified that during the inquest staff reported areas of confusion regarding the action of additional observations. The staff conveyed a lack of clarity regarding aspects such as arm’s length or within eyesight. Following the inquest the Trust’s Observation and Engagement of Service Users policy has been reviewed and updated to reflect the need for clarity in applying the observations as intended. I enclose a copy of the policy.” Source location 2015-0480-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 Mental health staff may be unable to accompany patient transfers in limited instances where safety makes accompaniment impossible.
Verbatim wording from the response “referenced below) that staff should wherever possible, accompany the patient during the transfer. There may be some limited instances where this is not possible on the grounds of safety but decisions would be made in liaison with other service involved.” Source location 2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
6 Aug 2015 THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Insufficient staffing capacity and unclear interim arrangements for coping with resulting difficulties View source Failure to maintain clinical review and care coordination during prolonged staff absence View source Failure to communicate medication changes and monitoring requirements to involved carers and family View source Failure to provide timely and continuous monitoring following medication changes 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
THOMAS THEO CHARLES THURLING · 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
Thomas Theo Charles Thurling, who had increasing depression, anxiety and suicidal ideation, was found dead at home on 28 October 2014 after he did not respond to visits. The inquest concluded that he took his own life, with medical cause of death recorded as asphyxiation. Concerns included medication changes not being adequately monitored, a prolonged absence of his Care Co-ordinator without alternative cover or review, and staff shortages.
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 Insufficient staffing capacity and unclear interim arrangements for coping with resulting difficulties
Wider context from the report “(3) It is clear from evidence given at the inquest that there is a shortage of staff at the Trust . Steps are being taken to try and address this but it is unclear as to what is being done in the meantime to cope with the difficulties that arise as a result .
” 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 clinical review and care coordination during prolonged staff absence
Wider context from the report “(2) Care Co-ordinator was on planned and unplanned leave from end September 2014 until the time of Mr Thurling's death. Her Line Managers were aware of this continuous absence. Prior to this there had been a general deterioration in Mr Thurling's mental health noted, he was clearly expressing suicidal ideation, He had attended A & E with thoughts of suicide and he had bought a penknife and cut his neck. His mother had contacted MH Team expressing her concerns on at least 2 occasions.
The Care Co-Ordinator had recommended a Nurse be appointed. Mr Thurling had a known fear of being abandoned by his family and MH Services. Mr Thurling was not reviewed during this period . No alternative Care Co-Ordinator was appointed .
” 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 communicate medication changes and monitoring requirements to involved carers and family
Wider context from the report “(1) On 13 August 2014 Mr Thurling's medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team. One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for . Despite close involvement, Mr Thurling's family were unaware of the change in medication and the request for monitoring .
Although Mr Thurling was seen daily by Mind they were unaware of any change in medication and the request for monitoring .
An Out Patient Review was not arranged until 6 weeks later.
Following that Out Patient Review the Care Co-Ordinator was absent from work on planned and unplanned leave. Nothing was put in place for monitoring the medication.
” 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 and continuous monitoring following medication changes
Wider context from the report “(1) On 13 August 2014 Mr Thurling's medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team . One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for. Despite close involvement, Mr Thurling's family were unaware of the change in medication and the request for monitoring.
Although Mr Thurling was seen daily by Mind they were unaware of any change in medication and the request for monitoring.
An Out Patient Review was not arranged until 6 weeks later .
Following that Out Patient Review the Care Co-Ordinator was absent from work on planned and unplanned leave. Nothing was put in place for monitoring the medication .
” 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 guidance requiring clinical teams to contact service users and assess alternative arrangements during planned or unplanned staff absence.
Verbatim wording from the response “In respect of cover for planned and unplanned absence of staff, the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts. Clinical services have been directed to consider how they are consistently meeting this guidance with feedback and further direction via the Trust’s Quality Governance Committee.” Source location 2015-0309-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 Pharmacy support for medication information to service users and families, including a medicines information helpline.
Verbatim wording from the response “Positively, many of our inpatient services have processes in place where the Pharmacy directly assist with providing information on medication to service users and their families. They also host a medicines information helpline which is available for service users and carers to use.” Source location 2015-0309-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 Raise medication-change monitoring directly with clinical staff through internal communications and clinical forums.
Verbatim wording from the response “Further, the matter will be raised directly with clinical staff via internal communications and clinical forums.” Source location 2015-0309-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 Employ temporary staff for defined periods to mitigate staffing-related risks and support service continuity.
Verbatim wording from the response “Contributing to the ability to apply this guidance is the staffing levels within a team, with some areas experiencing significant pressures. The Trust is taking active steps to recruit to these areas but we have found our experiences and challenges are shared across the health sector. The Trust is taking steps to mitigate the risks by employing temporary staffing for defined periods of time. This supports an element of consistency, however, our priority is to fill our vacancies with permanent staff. This is an area of focus for the Trust’s Executive and your concern mirrors ours.” Source location 2015-0309-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 Share medication-change monitoring concerns with Pharmacy, Triangle of Care leads and clinical teams for learning to be cascaded.
Verbatim wording from the response “In considering the means by which to ensure this practice is consistent, no single action will provide assurance. Recognising the task involves technical knowledge of medication and an understanding of the need to communication to the wider group of people involved in supporting the service user, we are sharing the issue with a range of leads in specific areas, such as the Pharmacy and those leading the implementation of Triangle of Care, as well as clinical teams. They will use this direction to cascade learning.” Source location 2015-0309-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 Direct clinical services to consider consistent compliance with staff-absence cover guidance, with feedback and further direction through the Quality Governance Committee.
Verbatim wording from the response “In respect of cover for planned and unplanned absence of staff, the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts. Clinical services have been directed to consider how they are consistently meeting this guidance with feedback and further direction via the Trust’s Quality Governance Committee.” Source location 2015-0309-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 Recruit permanent staff to community-service areas experiencing staffing pressures.
Verbatim wording from the response “Contributing to the ability to apply this guidance is the staffing levels within a team, with some areas experiencing significant pressures. The Trust is taking active steps to recruit to these areas but we have found our experiences and challenges are shared across the health sector. The Trust is taking steps to mitigate the risks by employing temporary staffing for defined periods of time. This supports an element of consistency, however, our priority is to fill our vacancies with permanent staff. This is an area of focus for the Trust’s Executive and your concern mirrors ours.” Source location 2015-0309-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 patient surveys, incident reports and complaints for failures to communicate treatment changes, taking remedial action where required.
Verbatim wording from the response “The most direct means by which the Trust will know it is consistently involving all parties in communication of changes to the service user's treatment is through measures such as the patient survey, incident reporting and complaints. The Trust will monitor specifically for this type of report taking remedial action where required.” Source location 2015-0309-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 Staffing pressures limit the Trust’s ability to apply absence-cover guidance consistently, with temporary staffing providing only partial mitigation pending permanent recruitment.
Verbatim wording from the response “Contributing to the ability to apply this guidance is the staffing levels within a team, with some areas experiencing significant pressures. The Trust is taking active steps to recruit to these areas but we have found our experiences and challenges are shared across the health sector. The Trust is taking steps to mitigate the risks by employing temporary staffing for defined periods of time. This supports an element of consistency, however, our priority is to fill our vacancies with permanent staff. This is an area of focus for the Trust’s Executive and your concern mirrors ours.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
23 Mar 2015 Barbara Mary Anne Mayer · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Unavailability of timely urgent mental health assessment during increased demand View source Failure to follow up signs of carer fatigue View source Failure to provide continuity of care View source Failure to discuss treatment reasoning and efficacy with patients 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
Barbara Mary Anne Mayer · 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
Barbara Mary Anne Mayer had a history of depression and was found drowned in a nearby pond on 16 November 2014 after leaving her house during the early hours. Concerns included carer fatigue not being followed up, lack of continuity in her care, treatments not being adequately discussed with her, and no urgent mental health assessment being available when she needed help on 14 November 2014.
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 Unavailability of timely urgent mental health assessment during increased demand
Wider context from the report “(4) Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014 . It is understood Doctors are now called out and on Call Manager can be contacted in such situations.
” 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 follow up signs of carer fatigue
Wider context from the report “(1) Mr ████████ was noted to show signs of Carer fatigue , but this was not followed up ;
” 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 continuity of care
Wider context from the report “(2) Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established . She had to repeat her history at each visit to a different person about personal details.
” 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 discuss treatment reasoning and efficacy with patients
Wider context from the report “(3) Different treatments were offered to Mrs Mayer without the reasoning or their efficacy being discussed with her .
” 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 Implement the Triangle of Care model to strengthen partnership working and support carers across services.
Verbatim wording from the response “The Trust is implementing the 'Triangle of Care' model which prescribes a therapeutic alliance between service user, carer and staff member that promotes safety, supports recovery and sustains wellbeing. The model, created by the Carers Trust, is aimed at partnership working.” Source location 2015-0113-Response-by-Norfolk-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 Crisis Resolution and Home Treatment team functions, including ways to improve consistency of staff contact with service users.
Verbatim wording from the response “The Crisis Resolution and Home Treatment (CRHT) team provide a 24 hour service, assessing and supporting service users with intensive treatment for defined periods of time. It has a team of fifty staff supporting a significant number of people across a large geographical area. These factors mean that planning and coordinating consistent staff contact with a service user is a challenge.” Source location 2015-0113-Response-by-Norfolk-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 Emphasise informed decision-making practice through clinical forums and the patient safety newsletter.
Verbatim wording from the response “This is recognised to be important because it is difficult to make informed decisions if the individual is not in receipt of all the required information. The Trust supports the best practice of informed decision making and is sorry this was not evident for Mrs Mayer.” Source location 2015-0113-Response-by-Norfolk-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 locality escalation plans for Crisis Resolution and Home Treatment and Dementia Intensive Support Team services to strengthen capacity escalation and contingency responses.
Verbatim wording from the response “The Trust is experiencing increasing demands for all of its services at a time of being challenged to make savings. It is recognised that when services such as the CRHT team reach levels of capacity there has to be robust mechanisms for escalation and contingency. To this end the localities across the Trust are reviewing their escalation plans for services such as CRHT and the Dementia Intensive Support Teams, both of which are required to respond to incoming referrals.” Source location 2015-0113-Response-by-Norfolk-Suffolk-NHS-Trust
Open published response
16 Jan 2015 Mark Robert Anstice · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Failure to assess physical ability and transport access before recommending group sessions View source Failure to communicate scheduled psychiatric appointments across the care team View source Failure to inform the service user about proposed help with practical barriers to group attendance View source Failure to establish contact and review non-attendance before discharge from mental health team View source Failure to make recommended carer’s assessment referrals View source Failure to action recommendations for support worker or care coordinator provision View source Difficulties in arranging cross-boundary carer’s assessment and service provision 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
Mark Robert Anstice · 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
Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.
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 physical ability and transport access before recommending group sessions
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions . He did not have the transport or means to attend such groups .
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
” 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 communicate scheduled psychiatric appointments across the care team
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team , despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014 .
” 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 inform the service user about proposed help with practical barriers to group attendance
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered .
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
” 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 establish contact and review non-attendance before discharge from mental health team
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014 , being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014 .
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
” 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 recommended carer’s assessment referrals
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made . Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
” 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 action recommendations for support worker or care coordinator provision
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned . The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
” 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 Difficulties in arranging cross-boundary carer’s assessment and service provision
Wider context from the report “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
” Open source report
4 Dec 2014 JO ANNE CAROL NOBBS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to investigate and act on correlations between deteriorating physical and mental health View source Failure to document and revise continuing care plans when engagement assumptions change 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
JO ANNE CAROL NOBBS · 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
Jo Anne Carol Nobbs had longstanding physical and mental health problems and was found dead at home on 2 June 2014 after disengaging from professionals and stopping collection of her medications. Concerns included failure to investigate or act on the relationship between her deteriorating physical and mental health, and the lack of a revised care plan when she stopped engaging with mental health services.
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 investigate and act on correlations between deteriorating physical and mental health
Wider context from the report “(1) A correlation between Miss Nobbs’ deteriorating physical health and her deteriorating mental health was noted by some mental health professionals and documented in her mental health records but this was not investigated or acted upon by other mental health professionals , despite Miss Nobbs attending at A & E Department, Norfolk & Norwich University Hospital on at least 10 occasions between January and March 2014 presenting with a variety of symptoms and at varying times of day and night
” 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 and revise continuing care plans when engagement assumptions change
Wider context from the report “(2) A Care Plan was put in place in January 2014 of steps to be taken on the basis that Miss Nobbs was going to engage with mental health services. The evidence is that this plan was kept under review and was a “continuing” plan. There is no documentation supporting such a continuing plan, particularly when Miss Nobbs was no longer engaging with mental health services. She had not been seen on a 1:1 basis before 26th February 2014 by any of the Community Mental Health Team, save in respect of a believed sighting in the street. There is no evidence of a revised Care Plan being put in place , save in respect of continuing to try to make contact with Miss Nobbs.
” Open source report
11 Sep 2014 ANN MARY WELLS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Unsafe positioning of light switches beside beds View source Lack of risk assessment for room placement 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
ANN MARY WELLS · 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
Ann Mary Wells, a resident of Julian Hospital, fell in her room on 21 November 2013 while attempting to access the wall beside her bed, sustaining a fractured pelvis and later dying on 28 December 2013. The concerns identified were the positioning of the light switch beside her bed and the absence of a risk assessment for placing her in that room.
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 Unsafe positioning of light switches beside beds
Wider context from the report “(1) A light switch was positioned on the wall beside Mrs Wells’ bed (see attached a photograph). Mrs Wells was 77 years of age, frail with scoliosis, osteoarthritis and a history of falls. In light of the fact that she had been diagnosed with dementia and had a sitting position in bed, it could have been reasonably foreseen that she might attempt to reach for the light switch . Her fall resulted in a fractured pelvis and subsequent complications.
” 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 for room placement
Wider context from the report “(2) No risk assessment had been carried out with regard to Mrs Wells being placed in this particular room .
” Open source report
23 Jul 2014 Graeme Alexander Kidd · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Delays in urgent mental health referrals caused by a mandatory physical health check View source Lack of locum doctor access to electronic care records and related systems View source Failure to ensure locum doctors know available local mental health support teams and referral criteria View source Unavailability of medication-taking advice when the prescribing doctor is absent View source See 1 more concern
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
Graeme Alexander Kidd · 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
Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.
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 Delays in urgent mental health referrals caused by a mandatory physical health check
Wider context from the report “(3) GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check , thereby causing delay in cases requiring urgent referral
” 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 locum doctor access to electronic care records and related systems
Wider context from the report “(1) Locum Doctors do not have access to electronic CareNotes and other electronic records and systems relating to Patients
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure locum doctors know available local mental health support teams and referral criteria
Wider context from the report “(2) Locum Doctors are not aware of the various local mental health support Teams available and the criteria which should be used when considering referral to an appropriate part of the service
” 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 medication-taking advice when the prescribing doctor is absent
Wider context from the report “(4) In the absence of the prescribing Doctor, no-one was available to advise the patient as to how the medication was to be taken.
” Open source report
7 Apr 2014 Jamie Raymond Barlow · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of clarity about the tasks requested from police assistance View source Failure to review the operating processes View source Failure to maintain effective inter-agency working View source Lack of an inter-agency protocol for jointly managing mental health assessments where risk is perceived View source See 1 more concern
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
Jamie Raymond Barlow · 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
Jamie Raymond Barlow had been receiving mental health support after concerns were raised about his wellbeing, but communication and coordination between services affected plans for a further assessment. He subsequently failed to attend a GP appointment and was found hanging near his home; concerns included better inter-agency working, clarity about police assistance, and processes for jointly managing mental health assessments where risks were perceived.
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 clarity about the tasks requested from police assistance
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do , a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.
” 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 the operating processes
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here , and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.
” 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 effective inter-agency working
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working , clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.
” 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 an inter-agency protocol for jointly managing mental health assessments where risk is perceived
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public .
” Open source report
12 Sep 2013 Matthew Christopher Dunham · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 6 Failure to recognise and act on suicide or serious self-harm risk View source Lack of coordination and information sharing between mental health professionals View source Failure to provide mental health professionals with access to complete patient records and practitioner actions View source Failure to draft letters to general practitioners appropriately View source Lack of shared understanding of team referral roles and interfaces View source Delays in following up emergency referrals View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew Christopher Dunham · 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
Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.
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 and act on suicide or serious self-harm risk
Wider context from the report “c) On the 8th of April 2013, despite the fact that Mr Dunham was presenting as feeling suicidal and specifically that he had set up a noose in his flat the previous night, it was not thought appropriate to refer him to the crisis team for appropriately robust intervention . This raises the issue of the basis upon which the risk of suicide or serious self harm is recognised and acted upon particularly where the person concerned has gone beyond vague suicidal ideation and moved towards contemplating some specific way of ending his life.
” 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 coordination and information sharing between mental health professionals
Wider context from the report “e) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8th of April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014.
” 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 mental health professionals with access to complete patient records and practitioner actions
Wider context from the report “e) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8th of April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners . It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014.
” 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 draft letters to general practitioners appropriately
Wider context from the report “d) A letter sent to Mr Dunham's general practitioner from the advice and assessment team was not drafted appropriately . This raises the issue of the need for specific guidance to be given about how such letters should be drafted within a template structure.
” 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 shared understanding of team referral roles and interfaces
Wider context from the report “b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too . There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate . This highlights the need for there to be a clear understanding about the roles of each team and the interface between them.
” 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 following up emergency referrals
Wider context from the report “a) An emergency referral by the general practitioner to the assessment team on the 4th of April 2013 was not followed up within the normal time scale of four hours and it was two days before a telephone triage session took place and four days before the assessment was undertaken by a mental health nurse . This raises the need to ensure that emergency referrals are dealt with within the appropriate time scale and that policies and procedures are in force to make sure that this happens.
” 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 Increase service resources to respond to referrals within timeframes matched to assessed urgency.
Verbatim wording from the response “The Trust’s internal investigation (Root Cause Analysis) identified this gap in responding to the requested assessment. Since this period the service has made a number of resource changes to be in a position to respond to referrals within the specified time period, according to the assessed urgency.” Source location Response
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 Develop and implement an agreed general-practitioner letter template presenting key information clearly.
Verbatim wording from the response “The Trust's internal investigation identified that whilst all of the information was within the letter to the GP it was presented in a way that key aspects were not readily visible. To address this, the AAT have been working with general practitioners to develop a template that provides information in a manner to meet their needs. The agreed template is due to be implemented from the 18th November 2013” Source location Response
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 an updated system that searches all Trust electronic health records, including PC Mis, to identify current and historical psychological-therapy care episodes.
Verbatim wording from the response “The Trust's internal investigation confirmed that the computer system employed by AAT at the time was able to scan all the Trust electronic health record systems with the exception of the electronic health record system named PC Mis. This meant that it was not readily identified if a patient was attending the Trust's Improving Access to Psychological Therapies (IAPT) service. The Trust has now implemented an updated system (Apverita) which is able to include the system PC Mis and therefore identify any current or historical care episodes an individual has with the IAPT service.” Source location Response
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 the assessment structure and clinicians’ judgements to support further development of suicide-risk assessment.
Verbatim wording from the response “The Trust's internal investigation recognised that the AAT is a new service (commenced in February 2013). The investigation recommended that an audit be completed to seek assurance on the robustness of the assessment structure, both from the perspective of the framework and clinician's individual judgements within it. This will provide the evidence to support further developments in the assessment of suicide risk alongside the Trust's current mandatory training programme. This audit is currently in progress and I would be happy to share a copy of its report upon conclusion.” Source location Response
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 Work towards implementing a single electronic health record across the Trust’s services.
Verbatim wording from the response “E) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8 April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014.” Source location Response
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 urgent referrals against the four-hour standard through daily reporting, senior oversight, and clinical review of contact and minimum telephone-contact requirements.
Verbatim wording from the response “The Trust has implemented monitoring mechanisms for the four hour 'urgent referral' standard which is reported daily to commissioners and is monitored by senior managers and clinicians.” Source location Response
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 Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.
Verbatim wording from the response “To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support.” Source location Response
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