Concerns raised 6 Lack of clear responsibility for care pending further mental health appointments View source Failure to provide medication risks and further-assistance contact information View source Failure of GPs to recognise their responsibility for prescribing and medication advice View source Failure to ensure patients know how to request discussion with a consultant psychiatrist View source Non-prescriber mental health staff advising GPs on medication View source Failure to ensure GPs know how to contact the duty psychiatrist View source See 3 more concerns
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AI-generated summary
Edward Angus Mallen · 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 Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.
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 Orchard Surgery, Melbourn; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care pending further mental health appointments
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal. In either event he should have been told who to call to get further assistance.
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments .
” 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 Orchard Surgery, Melbourn; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medication risks and further-assistance contact information
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal . In either event he should have been told who to call to get further assistance .
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments.
” 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 Orchard Surgery, Melbourn; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to recognise their responsibility for prescribing and medication advice
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status. The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Orchard Surgery, Melbourn; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients know how to request discussion with a consultant psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment .
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Orchard Surgery, Melbourn; that does not assign responsibility.
PFD Monitor interpretation Non-prescriber mental health staff advising GPs on medication
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status . The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Orchard Surgery, Melbourn; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure GPs know how to contact the duty psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment.
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this .
” 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