20 May 2026 Ricky Crosher and Matthew Osborne · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Failure to retain evidence pertinent to deaths View source Failure to ensure a safe and productive working relationship between prison and healthcare staff View source Failure to maintain an appropriately staffed and resourced Safer Custody function View source Failure to provide a safe Care and Separation Unit meeting expected policy and minimum standards of decency View source Persistent failure to maintain a robust system for learning from deaths View source Failure to maintain a robust system for managing the safer custody telephone line View source See 3 more concerns
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AI-generated summary
Ricky Crosher and Matthew Osborne · 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
Ricky Crosher and Matthew Osborne were prisoners at HMP Lowdham Grange who died by suicide in October and November 2023, respectively. Both had been identified as at increased risk of suicide and self-harm and placed on ACCT plans, but the plans and welfare checks were not managed in accordance with policy. The report identified concerns about Safer Custody staffing and systems, the safety and management of the Care and Separation Unit, learning from deaths, retention of evidence, and cooperation between prison and healthcare staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain evidence pertinent to deaths
Wider context from the report “5. Failure to retain evidence pertinent to the death
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a safe and productive working relationship between prison and healthcare staff
Wider context from the report “6. Failure to ensure a safe and productive working relationship between prison and healthcare 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an appropriately staffed and resourced Safer Custody function
Wider context from the report “1. Failure to have in place an appropriately staffed and resourced Safer Custody function
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a safe Care and Separation Unit meeting expected policy and minimum standards of decency
Wider context from the report “3. Failure to provide a safe Care and Separation Unit which adhered to expected policy and minimum standards of decency
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Persistent failure to maintain a robust system for learning from deaths
Wider context from the report “4. Persistent failure to have in place a robust system for learning from deaths
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a robust system for managing the safer custody telephone line
Wider context from the report “2. Failure to have in place a robust system for managing the safer custody telephone line
” 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 Head of Healthcare leadership, cross-team meeting participation, strategic planning, and competent deputy cover to support integrated working.
Verbatim wording from the response “Our Head of Healthcare plays a key role in facilitating integrated working practices between healthcare and prison teams. They are a core member of, and consistent attendee at, key meetings at the prison including a new Tri-partite Meeting, which deals with issues concerning safer custody, security, and drug strategy, and the Local Delivery Board, whose members also include NHS England and the Local Authority. A member of the strategic leadership team, the Head of Healthcare has also contributed to an integrated two-year strategy for the prison. If the head of healthcare is unable to attend (e.g., due to annual leave or training), then a suitably competent colleague deputises on their behalf to ensure continuity of services provided and sustained improved working relationships between the Trust and HMP Governor(s).” Source location Response from Northamptonshire Healthcare NHS Foundation 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 Attend daily ACCT reviews with prison staff to identify prisoners who may require additional support.
Verbatim wording from the response “Members of our healthcare team contribute to a range of meetings with prison staff including the Prison Council, the Specialist Interventions meeting, and two new meetings – the ‘Top 30 Most Violent’ meeting, and Segregation meeting. The latter two meetings have been put in place to embed strategies for reducing violence across the prison, and to safely manage transitions between ‘normal location’ and the ‘segregation unit’. Members of our team now attend daily ACCT reviews with prison staff enabling early identification of those that may require additional support.” Source location Response from Northamptonshire Healthcare NHS Foundation 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 Operate a joint Duty Manager Rota providing a senior-manager contact during core hours for resolving or escalating prison-healthcare issues.
Verbatim wording from the response “Beyond meetings, we have also collaborated with the prison team to establish a Duty Manager Rota. This provides a single point of contact for both prison and healthcare staff during core hours to a senior manager to resolve issues that may arise or to ensure they are escalated to the appropriate organisation for resolution where this is not possible.” Source location Response from Northamptonshire Healthcare 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 Host Governor-grade prison colleagues in healthcare staff briefings at least monthly to reinforce integrated working.
Verbatim wording from the response “We have welcomed Governor-grade colleagues from the prison team into healthcare staff briefings on at least a monthly basis, which helps reinforce the integrated approach between prison and healthcare teams we know from experience to be the most successful.” Source location Response from Northamptonshire Healthcare NHS Foundation 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 Participate in prison-healthcare meetings, including violence-reduction and segregation meetings, to support safer custody and transitions.
Verbatim wording from the response “Members of our healthcare team contribute to a range of meetings with prison staff including the Prison Council, the Specialist Interventions meeting, and two new meetings – the ‘Top 30 Most Violent’ meeting, and Segregation meeting. The latter two meetings have been put in place to embed strategies for reducing violence across the prison, and to safely manage transitions between ‘normal location’ and the ‘segregation unit’. Members of our team now attend daily ACCT reviews with prison staff enabling early identification of those that may require additional support.” Source location Response from Northamptonshire Healthcare NHS Foundation Trust
Open published response
8 Apr 2026 Jonathan Mark Thornton · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Unavailability of NOMIS/DPS alerts to Healthcare Staff View source Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff View source Failure to equip operational prison staff to identify and report behavioural deterioration View source Failure to communicate monitoring plans to the healthcare team View source Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff View source Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jonathan Mark Thornton · 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
Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of NOMIS/DPS alerts to Healthcare Staff
Wider context from the report “3. Categorisation and visibility of alerts on NOMIS/DPS
I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad. This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility, this gives rise to a risk of future death. I understand that this is controlled nationally.
Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts . This gives rise to the same risk .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners . It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this . I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to equip operational prison staff to identify and report behavioural deterioration
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for . Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate monitoring plans to the healthcare team
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team , but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff
Wider context from the report “3. Categorisation and visibility of alerts on NOMIS/DPS
I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad . This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility , this gives rise to a risk of future death. I understand that this is controlled nationally.
Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts. This gives rise to the same risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare
Wider context from the report “1. Information sharing between the CFT and Prison Healthcare.
During the course of the inquest, I heard that there had been various barriers to information sharing between the community forensic team and prison healthcare. There was no formal system in place for the handover of information between these teams at the time of Jonathan’s death or at the conclusion of the inquest. Prison Healthcare staff were often unavailable or uncontactable for handover meetings . The handover of information between CFT and Prison Healthcare is vital for the risk assessment and management of prisoners who are known to the CFT (often some of the most complex and high-risk prisoners). I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish regular information-sharing through daily briefings, SIM meetings, drug-strategy discussions, and communication across prison operational and healthcare teams.
Verbatim wording from the response “Since taking over responsibility for healthcare services at HMP Nottingham on 19 November 2025, we have put in place regular and consistent ways of sharing information within the prison. This includes routine contact through daily morning briefings, SIM meetings, drug strategy discussions, and ongoing conversations with colleagues in reception, healthcare, and across the house blocks.” Source location Response from Northampton Healthcare 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 Establish practical information-sharing arrangements and named contacts between community forensic and prison healthcare teams.
Verbatim wording from the response “We have put practical arrangements in place between the Community Forensic Team and the Prison Healthcare Team at HMP Nottingham to make sure information is shared smoothly when someone comes into custody. This includes holding named contacts in each team.” Source location Response from Northampton Healthcare NHS Foundation Trust
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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 Ministry of Justice is responsible for NOMIS/DPS alerts, so it will lead the response to concerns about their categorisation and visibility.
Verbatim wording from the response “Your Report acknowledges that the Ministry of Justice (MoJ) is responsible for the NOMIS/DPS and states that you have sent a copy of this report to the Ministry of Justice for their response. We shall therefore defer to the MoJ in responding to your concerns about alerts within NOMIS/DPS.” Source location Response from Northampton Healthcare NHS Foundation Trust
Open published response
17 Feb 2026 Edward James HANDS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 5 Failure to recognise and escalate clinical deterioration View source Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence View source Failure to observe and monitor prisoners suspected to be under the influence of illicit substances View source Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances View source Failure to arrange follow-up medical assessment when a prisoner's condition is not improving View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Edward James HANDS · 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
Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.
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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and escalate clinical deterioration
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated .
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence .
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to observe and monitor prisoners suspected to be under the influence of illicit substances
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed ; had these checks and monitoring taken place , it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols . Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange follow-up medical assessment when a prisoner's condition is not improving
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required . This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.
” 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 Facilitate mandatory induction training for healthcare staff on detecting and managing suspected illicit-substance influence.
Verbatim wording from the response “The healthcare and prison service leadership teams circulated the UTI protocol and an amended UTI recording log to staff late last year. Mandatory training for healthcare staff on UTI detection and management is being facilitated by the Trust’s Resuscitation Lead and is part of our induction programme. An ‘Airways Champion’ has also been identified. The Airways Champion supports our leadership team in maintaining competence in airway management and suction machine use. They will also help deliver future UTI simulation training sessions.” Source location Response from Northamptonshire Healthcare NHS Foundation 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 Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.
Verbatim wording from the response “We have worked with the Prison Governor and Head of Safety to agree and implement a common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford. I have enclosed a copy of the protocol with this letter for your information.” Source location Response from Northamptonshire Healthcare NHS Foundation 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 Circulate the UTI protocol and amended UTI recording log to healthcare and prison staff.
Verbatim wording from the response “The healthcare and prison service leadership teams circulated the UTI protocol and an amended UTI recording log to staff late last year. Mandatory training for healthcare staff on UTI detection and management is being facilitated by the Trust’s Resuscitation Lead and is part of our induction programme. An ‘Airways Champion’ has also been identified. The Airways Champion supports our leadership team in maintaining competence in airway management and suction machine use. They will also help deliver future UTI simulation training sessions.” Source location Response from Northamptonshire Healthcare NHS Foundation Trust
Open published response
Concerns raised 2 Potential for over-sedation and death from combined sedative medications View source Failure to provide and implement specific warnings about the risks of over-sedation from additional non-prescribed medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Remind prescribing clinicians to assess and manage cumulative sedative burden, recognise oversedation, repeat unexpected observations, document findings and escalation decisions, and escalate concerns proactively.
Stated completedThe respondent said that this action was complete when they made their response on 5 January 2026. View source
Action
Introduce and routinely provide patients with a harm-minimisation leaflet covering polypharmacy, illicit substances, substance use alone, reduced tolerance, and medication initiation or titration risks.
Stated completedThe respondent said that this action was complete when they made their response on 5 January 2026. View source
Action
Remind secure-environment prescribers to discuss medication purposes, risks, interactions, follow-up, and document contemporaneous consultation advice.
Stated completedThe respondent said that this action was complete when they made their response on 5 January 2026. View source
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AI-generated summary
Fallon Leanne ADAMS · 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
Fallon Leanne Adams was found unresponsive and cold in her cell at HMP Peterborough on 9 February 2023 and was declared deceased after CPR and a negative heart trace. The inquest concluded that she died from intoxication by mixed drugs, with illicitly obtained medication having a high probability of causing her death. Concerns included the combined sedative effects of prescribed and non-prescribed medication, a lack of specific warnings about over-sedation and death, and inadequate welfare checks and observations.
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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Potential for over-sedation and death from combined sedative medications
Wider context from the report “• Whilst an inmate at HMP Peterborough Fallon ADAMS was prescribed methadone (for opiate withdrawal) and chlordiazepoxide (for alcohol withdrawal). She also took non-prescribed ████████ apparently obtained from an illicit source within the prison. All of these medications have a sedative effect which in combination have the potential to cause over sedation and death.
• The evidence seemed to show that at no stage was Ms ADAMS given a specific warning or advice stating that taking additional non-prescribed medication ████████ could result in over sedation and death.
• I also heard evidence in relation to Regulation 28 issues. Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and implement specific warnings about the risks of over-sedation from additional non-prescribed medication
Wider context from the report “• Whilst an inmate at HMP Peterborough Fallon ADAMS was prescribed methadone (for opiate withdrawal) and chlordiazepoxide (for alcohol withdrawal). She also took non-prescribed ████████ apparently obtained from an illicit source within the prison. All of these medications have a sedative effect which in combination have the potential to cause over sedation and death.
• The evidence seemed to show that at no stage was Ms ADAMS given a specific warning or advice stating that taking additional non-prescribed medication ████████ could result in over sedation and death .
• I also heard evidence in relation to Regulation 28 issues. Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented .
” 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 Remind prescribing clinicians to assess and manage cumulative sedative burden, recognise oversedation, repeat unexpected observations, document findings and escalation decisions, and escalate concerns proactively.
Verbatim wording from the response “In response to your Report, we have reminded our prescribing clinicians of our expectations concerning the assessment and management of cumulative sedative burden, recognition of over-sedation, and the need for proactive escalation where concerns are identified.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and routinely provide patients with a harm-minimisation leaflet covering polypharmacy, illicit substances, substance use alone, reduced tolerance, and medication initiation or titration risks.
Verbatim wording from the response “We have also introduced a new harm minimisation advice leaflet, which is now routinely provided to patients. This leaflet clearly outlines key risks, including polypharmacy, the use of illicit drugs alongside prescribed medication, the dangers of using substances alone in cells (particularly overnight), reduced tolerance following periods of abstinence, and the increased risk associated with medication initiation and titration periods.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind secure-environment prescribers to discuss medication purposes, risks, interactions, follow-up, and document contemporaneous consultation advice.
Verbatim wording from the response “We agree it is important that a patient is informed about the risk(s) of any medication(s) our clinicians prescribe, including those that may arise from interactions with other medications they may be taking, whatever the source.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
22 Dec 2025 Wendy Siobhan EYLES · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure to communicate medication changes between private and NHS psychiatric providers View source Failure of notification pathways to identify patients receiving private and NHS psychiatry View source Lack of a consistent protocol for patients receiving private and NHS psychiatry 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
Wendy Siobhan EYLES · 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
Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate medication changes between private and NHS psychiatric providers
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...".
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of notification pathways to identify patients receiving private and NHS psychiatry
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...".
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry . Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services . Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent protocol for patients receiving private and NHS psychiatry
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time ...".
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
” Open source report
22 Dec 2025 Wendy Siobhan EYLES · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment View source Lack of a protocol for patients receiving concurrent private and NHS psychiatry View source Failure to communicate medication changes between private and NHS psychiatric providers 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
Wendy Siobhan EYLES · 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
Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”.
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry . Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services . Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for patients receiving concurrent private and NHS psychiatry
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust . The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time ..”.
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate medication changes between private and NHS psychiatric providers
Wider context from the report “One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety ... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”.
It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient.
” Open source report
21 Oct 2025 Paul John APPLEBY · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Lack of Saturday court service 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
Paul John APPLEBY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Appleby was arrested for drink driving, remanded in custody, and advised to be seen by Court Liaison and Diversion before release. He was not seen by the team and was found deceased after jumping from the Grosvenor Centre on 22 February 2025; the concern was that the lack of a Saturday Court Service could give rise to future 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Saturday court service
Wider context from the report “I understand that the Liaison and Diversion Team at Northampton has not operated a Saturday Court Service for several years . Previously an ‘On Call’ service has been provided. I am concerned that this lack of service could give rise to future deaths .
” Open source report
30 Jan 2025 Shaun Kenny HALL · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure to record referrals View source Failure to identify the person declining a referral View source Failure to accept a referral despite available information indicating escalating suicide risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shaun Kenny HALL · 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
Shaun Hall had mixed anxiety, depressive disorder and emotionally unstable personality disorder, and was found deceased on 14 December 2023 after hanging himself. A referral to the Urgent Care and Assessment Team was declined despite information about escalating factors and his statement that he would take his own life if not allowed to see his children. The identity of the person who declined the referral was unknown and no notes were made of it.
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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record referrals
Wider context from the report “The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral.
Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the person declining a referral
Wider context from the report “The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral.
Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accept a referral despite available information indicating escalating suicide risk
Wider context from the report “The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral.
Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the referral.
” 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 Develop new risk management processes, including policy updates and revised risk documentation, for UCAT and crisis and community services.
Verbatim wording from the response “In response to several national drivers and as part of our Trust’s commitment to continuous improvement and learning from incidents, we are developing a range of new risk management processes, including policy updates, changes to risk management documentation and the commissioning of new training modules.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable UCAT and Talking Therapies staff to access full records for service users in their care.
Verbatim wording from the response “Having further examined the circumstances surrounding Mr Hall’s death, we have understood the need for a greater level of patient records visibility between UCAT and Talking Therapies staff. We have now enabled both UCAT and Talking Therapies staff to have full visibility of all records relating to the treatment of service users in their care.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend web-based call handling and recording systems to UCAT services and train staff to use them.
Verbatim wording from the response “We have heard the concerns you raised and have elected to expand the use of call handling and recording systems within the Trust to our Crisis Services. We currently use a web-based call handling product within our response hub and have begun the process of extending the product into the UCAT services. By the end of July 2025, we anticipate that we will have trained all staff in the use of this product. This product will improve the accuracy of our record keeping and our ability to provide reflective interventions with staff.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a record-keeping audit tool to govern the quality and content of clinical records.
Verbatim wording from the response “We expect all clinical staff to adhere to the record keeping standards of their respective professional body and to comply with our ‘Health Records Management and Keeping Standards Policy’. We emphasised the importance of record keeping at the time of the incident to all staff in the UCAT team as a result of our initial learning. We continue to track the team’s compliance with mandatory information governance training and have developed a new record keeping audit tool that ensures governance over the quality and content of records.” Source location Response from Northamptonshire Healthcare Foundation Trust
Open published response
14 May 2018 Gladys Kathleen Rich · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 8 Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input View source Failure of the Falls Prevention Service to proactively follow up required input View source Failure to transmit and resubmit completed falls action plans through the required process View source Failure to use appropriate falls referral thresholds View source Unavailability of required falls prevention equipment View source Failure to consider and action falls risk action plan advice View source Failure to make new falls prevention referrals after further falls View source Failure to identify falls risks during pre-assessment View source See 5 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
Gladys Kathleen Rich · 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
Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.
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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
Wider context from the report “3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Falls Prevention Service to proactively follow up required input
Wider context from the report “2. In relation to the Falls Prevention Service.
a) Despite Mrs Rich having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment . In the absence of any further contact, the service assumes that their input is no longer required . As is clear in the case of Mrs Rich, the prevention service was very much still required. Again, when the service was contacted in November 2016 the failure to receive a form or a response to the subsequent letter again led to an automatic assumption that input was no longer required despite the fact that this was the second referral to have been made in relation to Mrs Rich. It was explained in evidence that the reason the service cannot be more proactive is because they are inadequately resourced .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit and resubmit completed falls action plans through the required process
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile . Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted . Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate falls referral thresholds
Wider context from the report “b) The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required falls prevention equipment
Wider context from the report “d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and action falls risk action plan advice
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned . Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make new falls prevention referrals after further falls
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify falls risks during pre-assessment
Wider context from the report “a) Failure to identify Mrs Rich as a falls risk during a pre-assessment process , despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre-assessment check may not therefore be sufficiently robust .
” Open source report
Concerns raised 6 Failure to provide robust, effective and event-responsive complex case planning View source Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes View source Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records View source Failure to formalise multidisciplinary team meetings View source Failure to investigate suspected overdose events and apply learning outcomes View source Under-utilisation of enhanced case management for complex prisoners View source See 3 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
Ahmedreza Fathi · 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
Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.
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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide robust, effective and event-responsive complex case planning
Wider context from the report “1. Healthcare complex case planning was not robust or effective , and was not reviewed or updated in response to subsequent events . Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions . Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison .
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise multidisciplinary team meetings
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate suspected overdose events and apply learning outcomes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes . This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-utilisation of enhanced case management for complex prisoners
Wider context from the report “2. The enhanced case management system referred to in PSI 64/11 was under-utilised for a prisoner of this complexity and further consideration should be given to its role in situations of this nature.
” Open source report
12 Feb 2015 Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 8 Delay in allocating a key worker View source Poor and perfunctory risk assessment documentation View source Failure to update risk assessments with emerging risks View source Failure to set boundaries for patient leave View source Failure to communicate and review relevant clinical information before risk decisions View source Failure to discuss risk assessments with relevant staff View source Failure to conduct planned medication, diagnosis and treatment reviews View source Unavailability of ligature-proof doors and adequate ligature-risk controls View source See 5 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
Jane Marie Clark and Isobel Griffin · 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
Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.
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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in allocating a key worker
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August . The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor and perfunctory risk assessment documentation
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented .
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory .
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances .
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments with emerging risks
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th .
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment .
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to set boundaries for patient leave
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return .
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and review relevant clinical information before risk decisions
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave . Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss risk assessments with relevant staff
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct planned medication, diagnosis and treatment reviews
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.
” 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 Northamptonshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ligature-proof doors and adequate ligature-risk controls
Wider context from the report “Re Jane Marie Clark
1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.
2. She did not place any boundaries on the leave for example providing a time by which Jane was to return.
3. Risk assessment documentation generally was poor and appeared perfunctory.
Re Isobel Griffin
1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th.
2. The risk assessment was not updated with the events of the 7th.
3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature.
4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family.
5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment.
6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.
7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations