Concerns raised 4 Failure to complete standard community needs and treatment assessments View source Failure to provide appointments from allocated Community Psychiatric Nurses and key workers View source Lack of policy, guidance or framework governing standard community needs and treatment assessments View source Lack of policy or procedure governing the timing and conduct of appointments View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lynsey Ellen Dearden · 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
Mrs Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these processes.
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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete standard community needs and treatment assessments
Wider context from the report “2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place , and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appointments from allocated Community Psychiatric Nurses and key workers
Wider context from the report “1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025 . There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy, guidance or framework governing standard community needs and treatment assessments
Wider context from the report “2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or procedure governing the timing and conduct of appointments
Wider context from the report “1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place;
” 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 Monitor adoption of the Practice Note and appointment timescales through multidisciplinary-team and assurance audits, including scheduled follow-up audits.
Verbatim wording from the response “The Practice Note already referenced has been issued to all relevant senior leads with an expectation that the improvements are immediately operational. Timeframes have been agreed and will be monitored via multidisciplinary team and assurance audits. Two initial audits have been undertaken, one prior to the Christmas 2025 and one during the second week of January 2026 to assess the adoption of the Practice Note and expected timescales. Results indicate good compliance across the Inpatient, CRHTT and CMHT services. A further audit is scheduled for 3 months’ time and 12-18 months to provide assurance that these processes have been embedded.” Source location Response from North Staffordshire Combined Healthcare NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.
Verbatim wording from the response “Immediate actions taken:
In response to the PFD and our internal review, we have implemented the following:
A Practice Note issued highlighting the following,” Source location Response from North Staffordshire Combined Healthcare NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Trust Care Management Policy to incorporate the new processes, guidance, and audit assurance arrangements.
Verbatim wording from the response “These additional processes and clarifications will be added to the Trust Care Management Policy which is currently under review.” Source location Response from North Staffordshire Combined Healthcare NHS Trust
Open published response
Concerns raised 5 Failure to carry out scheduled ACCT observations View source Failure to maintain accurate and complete ACCT observation records View source Lack of a collective inter-agency response to learning lessons View source Failure to ensure transfer for psychiatric treatment where required View source Failure to ensure correct levels of observation up to constant watch View source See 2 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.
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AI-generated summary
Martin Samuel WILLIS · 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
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out scheduled ACCT observations
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.
” 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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and complete ACCT observation records
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted . The last correct entry was at 7 am with earlier omissions .
” 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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a collective inter-agency response to learning lessons
Wider context from the report “4. Whilst the prison service and the mental health providers have reviewed the circumstances of Mr Willis’s death, I am concerned that there should be a collective and not individual response to ensure that all lessons can be learned . I therefore recommend that there be an inter-agency review between the prison service and mental health services as to the mental health care provided to the late Mr Willis including the evidence at the inquest and the jury’s findings. In so doing, I do not purport to suggest what the outcome of the review should be.
” 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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure transfer for psychiatric treatment where required
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing .
” 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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure correct levels of observation up to constant watch
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing.
” Open source report
Concerns raised 2 Lack of mental health inpatient provision for people aged 14-25 View source Failure to provide age-appropriate transitional care when mental health inpatients turn 18 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
Sky Louise Rollings · 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
Sky Louise Rollings was transferred from a child and adolescent mental health hospital to an adult mental health unit on 4 November 2019 and died at Royal Stoke University Hospital on 9 November 2019, following an incident at Harplands Hospital. The inquest heard concerns about differences between child and adult mental health care and the lack of inpatient provision for people aged 14 to 25, which was considered to create a risk of further deaths.
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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health inpatient provision for people aged 14-25
Wider context from the report “During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions.
It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25 . It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting .
” 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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide age-appropriate transitional care when mental health inpatients turn 18
Wider context from the report “During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions .
It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting.
” Open source report
Concerns raised 2 Failure to ensure allocation of an appropriate Care Co-Ordinator View source Failure of Care Co-Ordinators to carry out required care coordination tasks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebecca Claire Pykett · 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
Rebecca Claire Pykett, who had a history of mental health difficulties including PTSD, was found deceased at home on 25 February 2019 after intentionally hanging herself using a tie fashioned into a ligature. The concerns identified included the absence of a system to ensure that a Care Co-Ordinator was allocated, and that the expected care co-ordinator role, including timely patient contact and care planning, was not carried out in her case. The report also describes routine allocation of consultant psychiatrists as a “box ticking” exercise to satisfy the patient record system.
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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure allocation of an appropriate Care Co-Ordinator
Wider context from the report “(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive.
(2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role . What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator.
(3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pyketts’ case.
(4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator . The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise , to satisfy the record keeping system.
(5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator.
” 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 North Staffordshire Combined Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Care Co-Ordinators to carry out required care coordination tasks
Wider context from the report “(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive.
(2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator .
(3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan . This did not happen in Rebecca Pyketts’ case.
(4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system.
(5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out a training package defining staff roles and responsibilities alongside the revised policy.
Verbatim wording from the response “Action: In conjunction with the policy review a training package will be developed which outlines the roles and responsibilities of staff. This to be rolled out to support the implementation of the revised policy.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and ratify standard operating procedures covering referral, triage and Care Coordinator allocation.
Verbatim wording from the response “During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. | 2 | Standing Operating procedures will be developed which will encompass the referral, triage and care coordinator allocation processes as identified through the process mapping exercise. | ████████ | October 31st 2021 | SOP will be ratified at directorate and trust level. The reports referred to in action 3 will provide assurance that standards are being met.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement procedures ensuring Care Coordinator allocation complies with the Trust Care Management Policy.
Verbatim wording from the response “(1) The revised Trust Care Management Policy provides details on the role of the Care Co-ordinator being responsible for co-ordinating patient care. On receipt of this notice, we reviewed our practice to provide assurance that there were no gaps in Care Co-ordinator provision. I can confirm that procedures have been implemented since the incident to ensure that the Trust policy is adhered to. This is monitored and reviewed on a monthly basis at internal performance meetings.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Care Management Policy to clarify required standards and support Community Mental Health Framework implementation.
Verbatim wording from the response “As the transformation process progresses there is a need to review our current policy in light of the above requirements whilst maintaining the standards that are embedded within the current CPA framework.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake process mapping to identify consistent Care Coordinator allocation practice and document existing developments.
Verbatim wording from the response “During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. | 1 | A process mapping exercise will be undertaken to ensure that there is consistency in practice and no gaps in the process. This will capture the developments in practice that have been implemented but for which we currently have no documented procedure. | ████████ | October 4th 2021 | NA” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train Care Coordinators on required allocation, assessment, care planning and review standards.
Verbatim wording from the response “(3) The revised Trust Care Management Policy provides expectation in terms of the timeframes required for allocation, assessment, care planning and review (see appendix 1). Training for all Care Co-ordinators has taken place to ensure that staff are aware of the full requirements of their role. Assurance that this process is followed is monitored through the weekly review of compliance reports, overseen by Team Leaders. This data is further reviewed at Service Manager and Associate Director Level with accountability being provided through Monthly Performance Review sessions with the Executive team.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional training clarifying Care Coordinator role expectations.
Verbatim wording from the response “(2) Since this incident, we have reviewed our processes and procedures and have clarified the expectations associated with the role of Care Co-ordinator through additional training. Weekly reports are reviewed by the Team Leaders to monitor the performance of all staff allocated as Care Co-ordinators. Individual staff members are provided with information pertaining to their individual case load with the expectation that they will address any outstanding issues, the following week’s report provide assurance that this has been done.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate Care Coordinators according to assessed clinical need and record the allocation in the electronic patient record.
Verbatim wording from the response “(4) Care Co-ordinators are allocated according to the patients assessed clinical needs. For many patients, it is appropriate that a consultant psychiatrist fulfils the role of a Care Co-ordinator should the patient remain on standard care. This is recorded in the Electronic Patient Record (EPR) using the Care Programme Approach (CPA) determination tool or the individual’s core assessment. The allocated Care Co-ordinator may change should the individual needs of the patient change. Therefore, the Trust can confirm that this is not treated as a “box ticking” exercise. This process is aligned to the Trust Policy.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Care Coordinator performance and compliance through weekly reports and management performance reviews.
Verbatim wording from the response “(2) Since this incident, we have reviewed our processes and procedures and have clarified the expectations associated with the role of Care Co-ordinator through additional training. Weekly reports are reviewed by the Team Leaders to monitor the performance of all staff allocated as Care Co-ordinators. Individual staff members are provided with information pertaining to their individual case load with the expectation that they will address any outstanding issues, the following week’s report provide assurance that this has been done.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care coordinators are allocated according to assessed clinical need, rather than routinely or merely to satisfy the electronic record system.
Verbatim wording from the response “(4) Care Co-ordinators are allocated according to the patients assessed clinical needs. For many patients, it is appropriate that a consultant psychiatrist fulfils the role of a Care Co-ordinator should the patient remain on standard care. This is recorded in the Electronic Patient Record (EPR) using the Care Programme Approach (CPA) determination tool or the individual’s core assessment. The allocated Care Co-ordinator may change should the individual needs of the patient change. Therefore, the Trust can confirm that this is not treated as a “box ticking” exercise. This process is aligned to the Trust Policy.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reported five-day allocation, patient contact and care-plan requirements are not stated in the current Trust Care Management Policy.
Verbatim wording from the response “Action 4
Finding: An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pykett’s case.” Source location 2021-0264-Response-from-North-Staffordshire-Combined-Healthcare_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations