Concerns raised 2 Failure to follow up and act on identified suicide risk View source Failure to communicate receipt and outcome of safeguarding correspondence to the responsible doctor View source
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. 6
Action
Develop a Mental Health Care Plan template for integration into SystmOne.
View source
Action
Review identified patients’ Mental Health Care Plans and discuss concerns at weekly clinical meetings.
View source
Action
Automatically refer suicide attempts by children under 16 to the Safeguarding Team.
View source
Action
Contact significant-concern patients after mental-health discharge notices and offer GP review appointments about ongoing support.
View source
Action
Read-code existing Mental Health Care Plans to trigger visible patient-record alerts.
View source
Action
Establish and weekly review a Patients of Significant Concern register, removing patients only when concern lessens or resolves.
View source See 3 more actions
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AI-generated summary
SOLOMON JAMES BEALEY · 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
Solomon James Bealey, aged 15, was found in his bedroom on 5 February 2015 with a bag over his head and a cord around his neck, having left a note to his family. Concerns included that no action or follow-up was taken after a nurse and doctor became aware of signs of stress and a previous suicide attempt, and that the doctor did not know letters sent to Solomon’s mother had been received.
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 Norwich Practices Health Centre and Walk-in Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up and act on identified suicide risk
Wider context from the report “(1) Solomon was taken to see a Nurse at the Walk In Clinic on 1 October 2014 for minor medical matters. The Nurse became concerned at signs of stress and was aware that in 2010 Solomon was found preparing to hang himself, and so arranged for an on call Doctor to see him. No action was taken. The Nurse expressed her concerns to a GP in the practice. A telephone call was made to a number believed to be that of the mother of Solomon, but it was a wrong number. The Doctor wrote to Solomon's mother on two occasions and received no reply. The matter was not pursued any further.
(2) Although the letters had been received by Solomon's mother who discussed this with Solomon and his father and it was decided to take no further action, the Doctor was unaware that the letters had been received.
(3) No follow up action was taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norwich Practices Health Centre and Walk-in Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate receipt and outcome of safeguarding correspondence to the responsible doctor
Wider context from the report “(1) Solomon was taken to see a Nurse at the Walk In Clinic on 1 October 2014 for minor medical matters. The Nurse became concerned at signs of stress and was aware that in 2010 Solomon was found preparing to hang himself, and so arranged for an on call Doctor to see him. No action was taken. The Nurse expressed her concerns to a GP in the practice. A telephone call was made to a number believed to be that of the mother of Solomon, but it was a wrong number. The Doctor wrote to Solomon's mother on two occasions and received no reply. The matter was not pursued any further.
(2) Although the letters had been received by Solomon's mother who discussed this with Solomon and his father and it was decided to take no further action, the Doctor was unaware that the letters had been received.
(3) No follow up action was taken.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Mental Health Care Plan template for integration into SystmOne.
Verbatim wording from the response “Action – The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system. As a result of this review, Mental Health Care Plans already in place have been read-coded. This triggers a patient status alert which is visible under the patient demographic box and on the patient’s home screen. Patients that we have identified will have a review of their care plan before 30.11.15 and any concerns will be discussed at our weekly clinical meeting.” Source location 2015-0403-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review identified patients’ Mental Health Care Plans and discuss concerns at weekly clinical meetings.
Verbatim wording from the response “Action – The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system. As a result of this review, Mental Health Care Plans already in place have been read-coded. This triggers a patient status alert which is visible under the patient demographic box and on the patient’s home screen. Patients that we have identified will have a review of their care plan before 30.11.15 and any concerns will be discussed at our weekly clinical meeting.” Source location 2015-0403-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatically refer suicide attempts by children under 16 to the Safeguarding Team.
Verbatim wording from the response “• Any suicide attempt made by a child under 16years will trigger an automatic referral to the Safeguarding Team.” Source location 2015-0403-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact significant-concern patients after mental-health discharge notices and offer GP review appointments about ongoing support.
Verbatim wording from the response “Action – For patients identified as a significant concern, discharge notices from the Mental Health team will trigger contact, via telephone, from the practice to the patient to offer an appointment for GP review to discuss ongoing need for support.” Source location 2015-0403-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Read-code existing Mental Health Care Plans to trigger visible patient-record alerts.
Verbatim wording from the response “Action – The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system. As a result of this review, Mental Health Care Plans already in place have been read-coded. This triggers a patient status alert which is visible under the patient demographic box and on the patient’s home screen. Patients that we have identified will have a review of their care plan before 30.11.15 and any concerns will be discussed at our weekly clinical meeting.” Source location 2015-0403-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and weekly review a Patients of Significant Concern register, removing patients only when concern lessens or resolves.
Verbatim wording from the response “Action - We have a standing agenda item ‘Patients of Concern’ at our weekly clinical meeting. With immediate effect, we have agreed to have a ‘Patients of Significant Concern’ register. Patients will be added as agreed at the clinical meeting and the register will be reviewed weekly. Patients will only be removed from the list if the level of concern has lessened or resolved.” Source location 2015-0403-Response
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations