12 Feb 2026 Barry HARMER · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 11 Unavailability of beds under agreed or prescribed care and treatment plans View source Lack of robustness in incident learning and patient safety incident investigations View source Lack of consistent understanding within and between care teams View source Failure to communicate bed availability issues or obstructions to families View source Inconsistent operation of daily patient flow meetings View source Failure to provide proactive communication to community patients and their families View source Delays in implementing identified safety actions View source Failure to provide immediate escalation of changing community psychiatric needs when voluntary admission is agreed but no bed is available View source Failure to reinforce safety plans during waits for beds View source Failure to revisit internal investigations in light of emerging concerns and evidence View source Lack of face-to-face psychiatric review in community care View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Barry HARMER · 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
Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of beds under agreed or prescribed care and treatment plans
Wider context from the report “(4) Evidence confirms that Oxford Health has access to the same Trust bed spaces in Buckinghamshire and Oxfordshire for detained and voluntary patients, within and without the older adult criteria, however the evidence indicated that bed availability as part of an agreed or prescribed care and treatment plan remains a significant issue .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robustness in incident learning and patient safety incident investigations
Wider context from the report “(1) Whilst evidence was given at the Inquest of fresh and additional learning that had arisen during the coronial investigation and as a result of the evidence given in person by Oxford Health staff and others, it was clear that the initial Incident Learning Huddle and subsequent Patient Safety Incident Investigation (PSII) undertaken in 2024 lacked robustness and did not appear to have been revisited in the light of the emerging family concerns and evolving evidence during the coronial investigation. The need for proactive backwards reflection on internal investigations is essential in informing learning going forward.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding within and between care teams
Wider context from the report “(5) Evidence from Oxford Health, acknowledged in a candid manner, that the Trust had listened to witnesses and the family during the Inquest and there was more to be taken back to identify further actions to be implemented. The broader issues of consistent understanding within and between Trust teams and with proactive communication with patients in the community and their families will remain of concern if they are not addressed in policy and training going forward. The very fact that learning was still being discussed and identified in January 2026 when Barry died in April 2024 indicates the importance of the timely implementation of identified actions
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate bed availability issues or obstructions to families
Wider context from the report “(2) At the Inquest there was variable evidence as to the operation of the daily Patient Flow Meetings, during which patients requiring beds would be matched to availability based on individual needs. Communication to families of issues or obstructions to bed availability and reinforcement of safety plans during any period of wait for a bed should be a central feature of these daily meetings.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent operation of daily patient flow meetings
Wider context from the report “(2) At the Inquest there was variable evidence as to the operation of the daily Patient Flow Meetings , during which patients requiring beds would be matched to availability based on individual needs. Communication to families of issues or obstructions to bed availability and reinforcement of safety plans during any period of wait for a bed should be a central feature of these daily meetings.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide proactive communication to community patients and their families
Wider context from the report “(5) Evidence from Oxford Health, acknowledged in a candid manner, that the Trust had listened to witnesses and the family during the Inquest and there was more to be taken back to identify further actions to be implemented. The broader issues of consistent understanding within and between Trust teams and with proactive communication with patients in the community and their families will remain of concern if they are not addressed in policy and training going forward. The very fact that learning was still being discussed and identified in January 2026 when Barry died in April 2024 indicates the importance of the timely implementation of identified actions
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing identified safety actions
Wider context from the report “(5) Evidence from Oxford Health, acknowledged in a candid manner, that the Trust had listened to witnesses and the family during the Inquest and there was more to be taken back to identify further actions to be implemented. The broader issues of consistent understanding within and between Trust teams and with proactive communication with patients in the community and their families will remain of concern if they are not addressed in policy and training going forward. The very fact that learning was still being discussed and identified in January 2026 when Barry died in April 2024 indicates the importance of the timely implementation of identified actions
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide immediate escalation of changing community psychiatric needs when voluntary admission is agreed but no bed is available
Wider context from the report “(3) The fact that Barry had not had any face to face psychiatric review at any point during the time he was open to Oxford Health was not addressed in the PSII and it remains unclear how this can be escalated for immediate attention in the community , where circumstances are changing, where the need for a voluntary admission has been agreed, but no bed is available .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reinforce safety plans during waits for beds
Wider context from the report “(2) At the Inquest there was variable evidence as to the operation of the daily Patient Flow Meetings, during which patients requiring beds would be matched to availability based on individual needs. Communication to families of issues or obstructions to bed availability and reinforcement of safety plans during any period of wait for a bed should be a central feature of these daily meetings.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to revisit internal investigations in light of emerging concerns and evidence
Wider context from the report “(1) Whilst evidence was given at the Inquest of fresh and additional learning that had arisen during the coronial investigation and as a result of the evidence given in person by Oxford Health staff and others, it was clear that the initial Incident Learning Huddle and subsequent Patient Safety Incident Investigation (PSII) undertaken in 2024 lacked robustness and did not appear to have been revisited in the light of the emerging family concerns and evolving evidence during the coronial investigation . The need for proactive backwards reflection on internal investigations is essential in informing learning going forward.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of face-to-face psychiatric review in community care
Wider context from the report “(3) The fact that Barry had not had any face to face psychiatric review at any point during the time he was open to Oxford Health was not addressed in the PSII and it remains unclear how this can be escalated for immediate attention in the community, where circumstances are changing, where the need for a voluntary admission has been agreed, but no bed is available.
” Open source report
23 Sep 2025 Christopher John Bird (“Chris”) · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Systemic failure in communication between mental health and primary care View source Failure of nhs.net email to reliably deliver important information to GP practices View source
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
Christopher John Bird (“Chris”) · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher John Bird died by suicide on 19 September 2024 after placing his head on a railway line near South Marston and being struck by a freight train. The report found that a mental-health response sent to primary care was not received, and that this communication failure meant he was not updated about his referral and more likely than not exacerbated his mixed anxiety and depression. It also raised concern about the reliability of nhs.net email for transmitting important information between mental-health and primary-care services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Systemic failure in communication between mental health and primary care
Wider context from the report “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice. She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024.
If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost;
During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again . It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nhs.net email to reliably deliver important information to GP practices
Wider context from the report “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice . She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024.
If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost ;
During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again. It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter.
” 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 Review AMHT communication practice, identify available changes and assess which options could strengthen controls against GPs missing important communications.
Verbatim wording from the response “Service Managers agreed to talk to their teams about how communication with GPs is happening and whether anything can/should be done to make an” Source location Response from Oxford Health NHS 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 Evaluate the DWF Hub’s DocMan process and use Trust governance processes to decide whether to adopt it across the other Hub teams.
Verbatim wording from the response “There are seven other Hub teams in Oxfordshire (eight in total with the DWF Hub being one). The plan is for the Trust to evaluate the use of DocMan by the DWF Hub and we will then utilise Trust governance processes to make a decision on whether the new process is adopted in each of the hubs.” Source location Response from Oxford Health NHS 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 Discuss AMHT communication practices with teams to identify whether improvements are needed.
Verbatim wording from the response “Service Managers agreed to talk to their teams about how communication with GPs is happening and whether anything can/should be done to make an” Source location Response from Oxford Health NHS 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 Use DocMan instead of email for DWF Hub referral-outcome communication with GPs, except when the referrer explicitly requests email.
Verbatim wording from the response “2. Primary Care Mental Health Hubs
The manager of the Didcot, Wantage and Faringdon Hub (”DWF Hub”) attended the inquest and provided you with some evidence on the day. They have introduced an immediate change to the practice at the DWF Hub. The change is that the DWF Hub has changed its practice, and now also uses the DocMan system as the means of communication with GPs with regard to the outcome of a referral. The team no longer uses email, save where there is an explicit request for email to be used by the referrer.” Source location Response from Oxford Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DocMan is considered effective, timely and secure for communication between Oxfordshire Talking Therapies and GPs.
Verbatim wording from the response “1. Oxfordshire Talking Therapies
The Oxfordshire talking therapies service was commissioned by the CCG/general practitioners for Oxfordshire, with an established practice by which the service communicates with GPs. This is a system called DocMan. That system has been the agreed process for many years and the Trust’s position is that it provides effective, timely and secure communication between Oxfordshire Talking Therapies and GPs.” Source location Response from Oxford Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust will not change AMHT communication practices until it understands available options, utility and potential consequences.
Verbatim wording from the response “improvement. Email communication with GPs is commonplace across AMHTs and the Trust must apply diligence to any decision to direct staff to change their practice. That is particularly so because managers are not aware of any similar incidents between AMHTs and GPs and the Trust is reticent to make what could be a significant change without being confident that it will have utility for service users of AMHT services.” Source location Response from Oxford Health NHS Foundation Trust
Open published response
5 Jun 2025 Cain Alex River Donald · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 8 Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community View source Failure to involve the Probation Service in discharge planning View source Lack of training or guidance for CRHTT staff on medication supervision and escalation View source Failure to escalate non-compliance with medication supervision instructions View source Failure to engage family members effectively in discharge planning View source Failure to supervise medication taking as specifically instructed View source Insufficient communication with family members about discharge risks and support needs View source Failure to rapidly coordinate complex discharge arrangements 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.
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AI-generated summary
Cain Alex River Donald · 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
Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge policy failing to specifically address Tribunal discharge directly from PICU to the community
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU . Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the Probation Service in discharge planning
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated ; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance for CRHTT staff on medication supervision and escalation
Wider context from the report “Post-discharge management of risk arising from medication compliance and multi-disciplinary team review.
(3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues . My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate non-compliance with medication supervision instructions
Wider context from the report “Post-discharge management of risk arising from medication compliance and multi-disciplinary team review.
(3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur . There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage family members effectively in discharge planning
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process .
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise medication taking as specifically instructed
Wider context from the report “Post-discharge management of risk arising from medication compliance and multi-disciplinary team review.
(3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication . By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days . Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication with family members about discharge risks and support needs
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer . The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge. Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to rapidly coordinate complex discharge arrangements
Wider context from the report “Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.
(1) The evidence revealed deficiencies in the way Mr Donald's discharge was planned and executed, specifically that his family and the Probation Services were not properly engaged in the discharge planning process when they were considered important mitigations in any risk Mr Donald posed to himself.
(2) There was insufficient communication and liaison with family members, including explaining Mr Donald's condition and risks on discharge and providing support to his partner as a carer. The Probation Service was not informed of the discharge meeting and should have been invited and participated; and Mr Donald’s family were unable to contribute effectively to the discharge process.
My principal concern was that the Trust's Discharge Policy did not seem to specifically envisage discharge to the community by a Tribunal directly from the PICU. Such a decision necessitates rapid coordination of complex discharge arrangements and effective engagement of relevant agencies and the family, which was absent in Mr Donald's discharge . Whilst the Trust has taken some action to acknowledge these issues, I remain concerned that the specific issues outlined above have not been adequately addressed.
” Open source report
10 Jan 2025 Jan Michael RACIBORSKI · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Failure to properly record risk assessment details View source
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
Jan Michael RACIBORSKI · 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
Jan Michael Raciborski, who had longstanding mental health issues and a brain injury, died at home on 5 February 2024 after hanging himself. The principal concern was that records of contacts with the Adult Mental Health Team contained no written risk assessments, creating risks of inadequate information sharing, misleading records, and difficulties investigating whether risks to life had been identified.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record risk assessment details
Wider context from the report “None of the records of contact with Mr Raciborski completed by the AMHT in the period from August 2023 to the date of Mr Raciborski’s death contained any written record of a risk assessment. I found that in Mr Raciborski’s case this absence did not impact his treatment and was not causative factor.
However my concern is that the failure to properly record the details of a risk assessment can lead to inadequate information sharing and the possibility of someone who relies upon the records gaining the wrong impression . In addition it does not allow the adequacy of the risk assessments to be properly investigated and could hinder investigations into deaths; which mean that a matter giving rise to a risk to life may not be identified in future investigations .
” 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 Discuss risk assessment and documentation during CPA discharge discussions.
Verbatim wording from the response “The team manager of the South Oxon Adult Mental Health Team also attended court on the first day of Mr Raciborski’s inquest and has subsequently listened to the audio recording of your summing up and findings of fact on the second day. The team manager’s attendance at the inquest in order to listen to the evidence provided further valuable insight into the contacts that the AMHT had with Mr Raciborski. Following the conclusion of the inquest, the team manager has taken local actions in relation to your concerns including (a) all supervisors in” Source location Response from Oxford Health NHS 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 Use a clinical audit tool to assess records against risk-assessment and risk-management documentation standards.
Verbatim wording from the response “The Trust Core Clinical Standards in Mental Health and Learning Disability Care Policy gives colleagues guidance and direction as to the requirements and recording of risk assessment and information for both inpatient and community settings. We developed a clinical audit tool in the autumn of 2024 in order to check patient records against the policy and the standards to which we aspire. The tool reviews the following areas relating to the recording of risk information:” Source location Response from Oxford Health NHS 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 Complete spot checks of clinical notes focused on the reported recording concerns.
Verbatim wording from the response “the Wallingford, Henley and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire and (b) a meeting in relation to CPA discharge discussions, within which the team discussed risk and how to document assessments of risk. The team manager will also complete spot checks of clinical notes with a focus on the concerns that you identified.” Source location Response from Oxford Health NHS 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 supervision training to all South Oxfordshire teams.
Verbatim wording from the response “the Wallingford, Henley and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire and (b) a meeting in relation to CPA discharge discussions, within which the team discussed risk and how to document assessments of risk. The team manager will also complete spot checks of clinical notes with a focus on the concerns that you identified.” Source location Response from Oxford Health NHS 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 Attend supervision training to refresh risk-assessment and documentation skills.
Verbatim wording from the response “The team manager of the South Oxon Adult Mental Health Team also attended court on the first day of Mr Raciborski’s inquest and has subsequently listened to the audio recording of your summing up and findings of fact on the second day. The team manager’s attendance at the inquest in order to listen to the evidence provided further valuable insight into the contacts that the AMHT had with Mr Raciborski. Following the conclusion of the inquest, the team manager has taken local actions in relation to your concerns including (a) all supervisors in” Source location Response from Oxford Health NHS 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 Ask the CRAM policy owner to consider whether an earlier policy review is required.
Verbatim wording from the response “The Trust’s Clinical Risk Assessment and Management (CRAM) Policy sets out the standards for assessment, formulation and recording of risk assessment. The policy was most recently updated in February 2023 and is due for next review in February 2026. I have asked the CRAM policy owner to consider if an earlier review is required, given your concerns.” Source location Response from Oxford Health NHS Foundation Trust
Open published response
25 Nov 2024 Jai · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Failure to provide a care co-ordinator or key worker after hospital discharge View source Failure of RiO and BTT teams to access each other’s clinical notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jai · 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
Jai was a 36-year-old GP who was found deceased on 27 April 2023 and had taken her own life. She had previously received mental health support, but after discharge from hospital no medium- or long-term plan was put in place and she was not under secondary mental health services at the time of her death. The concerns include the absence of a care co-ordinator or key worker after discharge and the continuing inability of teams using different electronic records systems to access each other’s clinical notes.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care co-ordinator or key worker after hospital discharge
Wider context from the report “1. The Trust’s own internal investigation highlighted the fact that no care co-ordinator or key worker was provided to Jai after her discharge from hospital on 7th of September 2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of RiO and BTT teams to access each other’s clinical notes
Wider context from the report “2. It is still not possible for teams using RiO and the BTT systems to access each other’s clinical notes .
” 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 Establish effective BTT staff access to the Trust’s RiO electronic health records system through documented procedures.
Verbatim wording from the response “For their part, some BTT staff have direct access to RiO, which is the electronic health records system used by the Trust’s secondary care services. Those staff include the admin team, referral co-ordinators in SPA, and supervisors. BTT’s standard operating procedure records the procedure for BTT staff to do so. I understand that you have received a copy of that operating procedure. I am satisfied that BTT’s access to RiO is established and effective for their purposes.” Source location Response from Oxford Health NHS 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 Progress the Quality Improvement project to make care-transfer changes sustainable, Trust-wide and effective in mitigating recurrence risk.
Verbatim wording from the response “In relation to your first concern, I acknowledge that a delay in the completion of an action that arises from a patient safety incident investigation is a concern. I have asked to receive a report from the Oxford Healthcare Improvement Manager by the end of January 2025. In the meantime, I am satisfied that the Quality Improvement project has been progressing well. The purpose of this project is for us to ensure that the changes made are sustainable and Trust wide and that they do indeed mitigate against the risk of a similar event. I have been informed that a meeting takes place every fortnight in order to review progress (the most recent meeting was on 17th December 2024). The Trust is clear about the critical importance of the process by which a patient’s care is transferred from a ward to community teams.” Source location Response from Oxford Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct secondary-care access to BTT records is not provided, but shared records and BTT’s established RiO access are considered sufficient.
Verbatim wording from the response “I understand that your second concern relates to records held by Buckinghamshire Talking Therapies (BTT). It was the case that members of our secondary care services did not have access to those records in 2022 and 2023. That remains the case, in that staff in secondary care services cannot log into BTT’s electronic records system direct. The position is that” Source location Response from Oxford Health NHS Foundation Trust
Open published response
20 May 2024 James Furlong and 2 others · Prevention of Future Deaths report Central Criminal Court
View report summary
Concerns raised 6 Failure to maintain and disseminate an adequate intelligence picture View source Failure to provide an adequate and integrated response to identified risk View source Failure to address consequential risks created by inadequate intelligence dissemination View source Failure to provide adequate secondary mental healthcare in prison View source Failure to provide adequate mental healthcare in the community View source Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Furlong and 2 others · 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
James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and disseminate an adequate intelligence picture
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate and integrated response to identified risk
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address consequential risks created by inadequate intelligence dissemination
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate secondary mental healthcare in prison
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate mental healthcare in the community
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Submit a business case to commissioners proposing staffing alternatives to increase and expand psychological provision at HMP Huntercombe.
Verbatim wording from the response “At HMP Huntercombe the current staffing model is one WTE band 4 assistant psychologist and 0.3 WTE band 8a psychologist. The service has not been able to fill these posts and a business case was submitted by the service to commissioners that proposed three alternatives to the staffing model. The purpose of the business case is to give us the best chance to recruit into posts, to increase the provision for psychology and to expand the service which can be offered. The business case has been submitted and we hope to receive a decision in July 2024. There are high levels of trauma within the establishment and the focus will be to treat the trauma and any associated symptoms.” Source location Response from Oxford Health
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 Consider introducing guidance on recording declined psychological treatment offers and reviewing them in caseload management supervision.
Verbatim wording from the response “In terms of actions that it will be helpful for the Trust to consider, the service will consider if they should introduce guidance for psychological therapy staff about what to record when an individual declines treatment in the prison pathway, to include guidance that declined offers of treatment are always considered in caseload management supervision.” Source location Response from Oxford Health
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 Introduce two band 5 psychological wellbeing practitioner posts at HMP Bullingdon.
Verbatim wording from the response “At HMP Bullingdon the current staffing model is a 0.8 whole time equivalent (WTE) band 7 psychotherapist, a 0.3 WTE band 8a forensic psychologist, and two band 5 psychological wellbeing practitioners who are currently due to start in the service in July 2024. In the past 12 months there have been 116 referrals for psychology, 17 patients are engaged in therapy currently, and 34 patients waiting. The average waiting time is around 14 weeks. We also have a Consultant Forensic Psychologist who oversees the governance of the psychological therapies pathways within the mental health teams, including managing caseloads of the psychologists and psychological therapists.” Source location Response from Oxford Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Psychological provision at HMP Huntercombe cannot currently be increased because staffing posts remain unfilled pending a commissioners’ decision on the proposed staffing model.
Verbatim wording from the response “At HMP Huntercombe the current staffing model is one WTE band 4 assistant psychologist and 0.3 WTE band 8a psychologist. The service has not been able to fill these posts and a business case was submitted by the service to commissioners that proposed three alternatives to the staffing model. The purpose of the business case is to give us the best chance to recruit into posts, to increase the provision for psychology and to expand the service which can be offered. The business case has been submitted and we hope to receive a decision in July 2024. There are high levels of trauma within the establishment and the focus will be to treat the trauma and any associated symptoms.” Source location Response from Oxford Health
Open published response
23 Feb 2022 Amanda Gibbens · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 2 Failure to ensure Level 3 constant “within eyesight” observations are conducted by direct visual observation View source Failure to conduct effective bedroom searches for prohibited self-harm items 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
Amanda Gibbens · 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
Amanda Gibbens died on 13 July 2020 at Stoke Mandeville Hospital after suffering a cardiac arrest while detained under Section 2 of the Mental Health Act at Ruby Ward. The concerns included the use of a monitor rather than continuous direct observation during Level 3 observations and ineffective bedroom searches for prohibited items that could be used for self-harm.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Level 3 constant “within eyesight” observations are conducted by direct visual observation
Wider context from the report “1. Using a monitor screen for Level 3 constant “within eyesight” enhanced observations.
The jury found in this case that the deceased could not be seen at all times whist in the de-escalation area, because male healthcare staff moved from observing the female patient from their position in the doorway of the de-escalation room, to view via the monitor in the corridor, when the patient moved into the bathroom, to increase her privacy. Although the Observation policy has been updated since this death in July 2020, by the time of the inquest, the use of the monitor for performing L3 observations was not specifically addressed or prohibited . Although the head of nursing was clear that this should no longer be happening in practice, the current Matron of Ruby ward gave evidence that this was still happening, and although it was now being ‘discouraged’, it was not prohibited .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct effective bedroom searches for prohibited self-harm items
Wider context from the report “2. Searching bedrooms on Ruby ward for prohibited items
The evidence in this case demonstrated that the deceased had prohibited items in her bedroom on Ruby Ward, including a ████████
████████ The search of the patient environment in July 2020 was not effective in identifying and removing items which could be used for self-harm by a detainee patient under the Mental Health Act, who was at risk of self harm. The evidence heard at the time of the inquest in February 2022 was that the bedroom searching process does not always include looking into or underneath a patient’s property in their room for concealed items , although some changes to the method and recording of searches are intended. A previous Report to Prevent Future Deaths to the Trust dated April 2019 also identified that the search process on Ruby ward was not effective .
” Open source report
29 Mar 2021 Roy Keith MORRIS · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 2 Failure to provide detailed CPA care plans that inform patients, families, care coordinators and community teams on discharge View source Delays in allocating care coordinators to inpatients shortly after admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Roy Keith MORRIS · 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
Roy Morris was found deceased in Birch Wood on 30 June 2019, having probably hanged himself there on the night of 26/27 May 2019. At the time, he was under the care of community mental health services after discharge from inpatient care. The substantive concerns were the absence of a detailed written care plan, the late allocation of a care coordinator, and insufficient opportunity for his family to engage with the inpatient team.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed CPA care plans that inform patients, families, care coordinators and community teams on discharge
Wider context from the report “1. The application of the CPA policy for patients such as Roy so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in allocating care coordinators to inpatients shortly after admission
Wider context from the report “2. Reinforcing the importance of the role of care coordinator and ensuring the timely allocation to inpatients shortly after admission so that they can work over a meaningful period with the patient, the family and the mental health teams in anticipation of the discharge into the community .
” 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 Appoint a patient flow manager to support care coordinator allocation and resolution of discharge-planning barriers.
Verbatim wording from the response “This will involve discussion at each ward’s rapid reviews (which are held three times per week on each of the acute wards) and escalations at our twice daily teleconferences (chaired by senior nurses and service managers) for our inpatient and our community teams. This work will be supported through the newly appointed patient flow manager and will strengthen the daily action log from the bed escalation meetings to quickly identify and resolve with service managers any barriers to completing the allocation of care coordinators. The revised bed meetings and escalations calls will ensure that we are allocating care coordinators at the earliest opportunity to support engagement in discharge planning.” Source location 2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care coordinator allocation structures, processes and role expectations within community mental health teams.
Verbatim wording from the response “- To review the standard operating policies for our community mental health teams to reflect the standards of practice expected in the role of care coordinator, which is pivotal to the delivery of care.
- To review the induction process and package for both permanent and locum staff, with an aide memoire for both existing staff and new and locum staff to familiarise themselves with the role and expected standard of practice for the role and their team’s structure and processes.
- To review the structure and process of care coordinator allocation within mental health community teams and the expectations of the role in order to ensure adherence of the Trust CPA policy.
- To review the daily bed management and escalations meetings to capture care co-ordinator allocation and clear communication between the mental health community teams and inpatient teams.” Source location 2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
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 Create a task and finish group of relevant clinicians to strengthen application of CPA policy and care coordinator practice.
Verbatim wording from the response “I will state immediately that as an organisation we understand and accept the concerns that you have raised. As stated in your report, our CPA policy stipulates the requirement of a detailed care plan and recommends that the individual (or patient) and their family are involved in designing the plan of care and support required to ensure a timely and smooth discharge from hospital. We have therefore sought to strengthen the understanding and application of our policy within our teams by creating a task and finish group with relevant clinicians. The group’s main functions will be as follows:” Source location 2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
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 Strengthen the bed-escalation action log and use rapid reviews and escalation calls to identify and resolve barriers to timely care coordinator allocation.
Verbatim wording from the response “This will involve discussion at each ward’s rapid reviews (which are held three times per week on each of the acute wards) and escalations at our twice daily teleconferences (chaired by senior nurses and service managers) for our inpatient and our community teams. This work will be supported through the newly appointed patient flow manager and will strengthen the daily action log from the bed escalation meetings to quickly identify and resolve with service managers any barriers to completing the allocation of care coordinators. The revised bed meetings and escalations calls will ensure that we are allocating care coordinators at the earliest opportunity to support engagement in discharge planning.” Source location 2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review bed-management and escalation meetings to capture care coordinator allocation and communication between inpatient and community teams.
Verbatim wording from the response “- To review the standard operating policies for our community mental health teams to reflect the standards of practice expected in the role of care coordinator, which is pivotal to the delivery of care.
- To review the induction process and package for both permanent and locum staff, with an aide memoire for both existing staff and new and locum staff to familiarise themselves with the role and expected standard of practice for the role and their team’s structure and processes.
- To review the structure and process of care coordinator allocation within mental health community teams and the expectations of the role in order to ensure adherence of the Trust CPA policy.
- To review the daily bed management and escalations meetings to capture care co-ordinator allocation and clear communication between the mental health community teams and inpatient teams.” Source location 2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
10 Feb 2021 LISA MARIE THOMPSON · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Failure to update care plans and risk assessments with material overdose information and information from clinical reviews and contacts View source Failure to record recent medication overdoses View source Lack of a clear care plan following emergency review 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
LISA MARIE THOMPSON · 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
Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update care plans and risk assessments with material overdose information and information from clinical reviews and contacts
Wider context from the report “Evidence was heard that:
(1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020
(2) The care plans and risk assessments at the mental health Trust were not updated :
(a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication.
(b) the two most recent overdoses were not recorded
(c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out.
(d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist
(e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record recent medication overdoses
Wider context from the report “Evidence was heard that:
(1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020
(2) The care plans and risk assessments at the mental health Trust were not updated:
(a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication.
(b) the two most recent overdoses were not recorded
(c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out.
(d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist
(e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear care plan following emergency review
Wider context from the report “Evidence was heard that:
(1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020
(2) The care plans and risk assessments at the mental health Trust were not updated:
(a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication.
(b) the two most recent overdoses were not recorded
(c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out.
(d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist
(e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator
” Open source report
12 Apr 2019 Emma Felicity BUTLER · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 9 Failure of searching and seizure processes to prevent introduction of self-harm materials after unescorted leave View source Variation in recording of hourly patient observations View source Failure to provide an immediate ward response to self-alerts about imminent or actual self-harm View source Unclear communication of discharge decision-making within the team and with the patient View source Lack of structured ongoing review of risk, leave decisions and medication effectiveness during discharge planning View source Variation in the timing and conduct of hourly patient observations View source Failure to monitor the handing out and proper return of plastic cutlery used at mealtimes View source Unclear understanding and compliance with leave conditions relevant to searches View source Unavailability of immediate support or assistance through the specific ward number View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Felicity BUTLER · 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
Emma Butler was an inpatient at Ruby Ward who died at Stoke Mandeville Hospital from blood loss after incised wounds inflicted outside the Whiteleaf Centre while she was on unescorted leave. The report raised concerns about access to means of self-harm on and outside the ward, hourly observations, urgent access to ward support, and planning for discharge.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of searching and seizure processes to prevent introduction of self-harm materials after unescorted leave
Wider context from the report “(2) Access to means of self-harm from outside the ward. The processes for searching and seizing potential self-harm material after return from unescorted leave did not prevent items being brought in from the outside at risk to the particular patient, other patients and staff and the evidence regarding the extent of strip or other searches from staff members was variable. The risk of items being brought onto the ward from outside for use by that patient or others remains where the system for searching and the nature and extent of that search has not prevented the introduction of such items. The understanding of and compliance with specific conditions of leave in the context of searches was unclear.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Variation in recording of hourly patient observations
Wider context from the report “(3) General observations. The process for conducting and recording hourly observations left scope for significant variation on the actual time between and the manner in which such observations of a particular patient were undertaken and recorded . There was an indication that this would be reviewed but the risk remains of an incident of planned or spontaneous self-harm occurring between observations for a patient not on a higher level of observations.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an immediate ward response to self-alerts about imminent or actual self-harm
Wider context from the report “(4) Urgent or emergency access to the ward phone. The concern remains that a patient on unescorted leave outside the Centre who felt they were going to self- harm or who had self-harmed may not get immediate access to support or assistance by calling the specific ward number given to them. Whilst the evidence indicated the balance between positive risk taking, unescorted leave and taking responsibility for decisions and actions, the risk remains that the safety net is not sufficiently robust to ensure that if such a potentially fatal incident occurs, or is likely to occur, a patient can self-alert the ward and expect to receive an immediate response.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear communication of discharge decision-making within the team and with the patient
Wider context from the report “(5) Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community. However, the process for keeping all aspects under review and communicating decision-making within the team and with the patient was unclear. The potential lack of certainty and structure in relation to ongoing assessment of risk, leave decisions and monitoring of medication effectiveness is of continuing concern in relation to the management of the risks and behaviour of a patient with personality disorder progressing towards discharge.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured ongoing review of risk, leave decisions and medication effectiveness during discharge planning
Wider context from the report “(5) Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community. However, the process for keeping all aspects under review and communicating decision-making within the team and with the patient was unclear. The potential lack of certainty and structure in relation to ongoing assessment of risk, leave decisions and monitoring of medication effectiveness is of continuing concern in relation to the management of the risks and behaviour of a patient with personality disorder progressing towards discharge.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Variation in the timing and conduct of hourly patient observations
Wider context from the report “(3) General observations. The process for conducting and recording hourly observations left scope for significant variation on the actual time between and the manner in which such observations of a particular patient were undertaken and recorded. There was an indication that this would be reviewed but the risk remains of an incident of planned or spontaneous self-harm occurring between observations for a patient not on a higher level of observations.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor the handing out and proper return of plastic cutlery used at mealtimes
Wider context from the report “(1) Access to means of self-harm on the ward. Whilst evidence was given as to the difficulty of reducing access to materials of self-harm without restricting fundamentally the rights and activities of patients, it was clear that incidences of self-harm had, on occasions related to the procuring of, concealment of and use of plastic cutlery available to patients on Ruby for self-cutting. The process appears reliant upon voluntary surrender of such items on or their being found rather than on the monitoring of the handing out and proper return of all such items in the context of use at mealtimes. There is a risk of self-harm within the patient cohort on Ruby Ward.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear understanding and compliance with leave conditions relevant to searches
Wider context from the report “(2) Access to means of self-harm from outside the ward. The processes for searching and seizing potential self-harm material after return from unescorted leave did not prevent items being brought in from the outside at risk to the particular patient, other patients and staff and the evidence regarding the extent of strip or other searches from staff members was variable. The risk of items being brought onto the ward from outside for use by that patient or others remains where the system for searching and the nature and extent of that search has not prevented the introduction of such items. The understanding of and compliance with specific conditions of leave in the context of searches was unclear.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of immediate support or assistance through the specific ward number
Wider context from the report “(4) Urgent or emergency access to the ward phone. The concern remains that a patient on unescorted leave outside the Centre who felt they were going to self- harm or who had self-harmed may not get immediate access to support or assistance by calling the specific ward number given to them . Whilst the evidence indicated the balance between positive risk taking, unescorted leave and taking responsibility for decisions and actions, the risk remains that the safety net is not sufficiently robust to ensure that if such a potentially fatal incident occurs, or is likely to occur, a patient can self-alert the ward and expect to receive an immediate response.
” 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 Review and revise the Safe and Supportive Observations policy to improve the safety and effectiveness of observation practices.
Verbatim wording from the response “The policy is currently undergoing a review. It was last discussed at the Clinical Effectiveness Sub-Committee in April 2019. Your concerns are being considered as part of that review. The revised policy will be presented to the Sub-committee on 18th July 2019 by the Trust’s Deputy Director of Nursing for Mental Health.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and evaluate new approaches to enhanced observations through a quality improvement project.
Verbatim wording from the response “I can also add that the issue of enhanced observations was the subject of a 2018/19 quality improvement project completed by Oxford Healthcare Improvement (OHI) in partnership with one of our wards, the results of which were reported to our Quality Committee in May 2019. OHI trains and develops staff at the Trust in order to deliver better and safer care through a programme of quality improvement projects, training and research. OHI works with national and international organisations, universities, health and social care providers, commissioners, the academic health science network, patient safety collaborative and industrial partners. The outcome of the project was extremely encouraging and patients and staff have reported very positive outcomes from new approaches to enhanced observations.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly ward reviews with patients and families to assess the risks and benefits of continued admission and make decisions collaboratively.
Verbatim wording from the response “• It is recognised that admission to hospital may contribute to an escalation of risk-behaviours and therefore a deterioration in a patient’s presentation. These issues are discussed with patients and their families in weekly ward reviews, where the benefits and risks of continued admission are explored and decisions made with patients.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify and consider more break-resistant alternatives to plastic spoons for patients at risk of self-harm.
Verbatim wording from the response “The Trust does not consider that it is practically possible to monitor every plastic spoon on the ward. The Trust is considering if plastic spoons can be replaced by an alternative product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is working with the matrons to identify if there is alternative cutlery available that may be more suitable for this patient group.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the leave documentation and welcome pack to clarify phone availability and emergency arrangements for patients on leave.
Verbatim wording from the response “One action that was discussed was to make it explicit within the leave documentation and welcome pack that when patients are on leave it is possible that the ward phone may not be answered, due to staff attending to the needs of patients on the ward; and to suggest to patients going on leave that if they feel the need to speak to a member of staff, it is suggested that they return to the ward, and speak with their allocated nurse. It should also underline that the ward is not able to provide an immediate response to patients who are on leave and that if patients require an urgent response whilst away from the ward they should contact the emergency services.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the policy governing searches of patients and their belongings, including risk-based search guidance and training access.
Verbatim wording from the response “████████ in his evidence used the term “strip search”, but what ████████ intended by the term, i.e. whether he intended to prescribe what a layperson would understand as a “strip search”, was not explored in evidence. The use of the term does not reflect the Trust’s policy. We agreed that the policy relating to the search of patients and their belongings ought to be updated, and that it ought clearly to set out the hierarchy of searching based on the dynamic assessed risk, as assessed by staff. There is clear instruction available to staff on ‘rub down’ searching, but no guidance on how to carry out a more extensive search, nor where training could be accessed for the same. It was suggested that a review of the Searching of Patients and their Belongings policy be undertaken. The policy is due before the Trust Quality Committee Clinical Effectiveness Sub-Committee in September 2019.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support crisis management in the community and keep admissions for patients with EUPD ideally to no more than seven days.
Verbatim wording from the response “The Trust has implemented significant changes since 2017 on Ruby ward in relation to the care of patients with a diagnosis of EUPD. The changes help to provide effective means by which clinical staff can keep under review and planning for a patient’s discharge into the community, ongoing assessment of risk, leave decisions and monitoring of medication effectiveness. The changes include:” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the clinical team to establish additional monitoring and review measures for patients with EUPD admitted for longer periods.
Verbatim wording from the response “• We continue to work with the clinical team on the ward to establish other measures we can put in place for monitoring and review of a patient with EUPD if they are admitted to the ward for a longer period of time.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is not practically possible to monitor every plastic spoon on the ward, although alternative, more break-resistant cutlery is being considered.
Verbatim wording from the response “The Trust does not consider that it is practically possible to monitor every plastic spoon on the ward. The Trust is considering if plastic spoons can be replaced by an alternative product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is working with the matrons to identify if there is alternative cutlery available that may be more suitable for this patient group.” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ward cannot guarantee an immediate phone response because staff must prioritise patients physically present on the ward.
Verbatim wording from the response “I understand that our (then) Ruby ward Modern Matron confirmed in evidence that it is possible that the ward phone number given to patients will go unanswered at times, if a patient on leave (or a relative) attempts to make contact; and that it is right that the focus of ward staff on shift should be towards meeting the needs of patients who are physically present on the ward. Although ward staff have a role in attempting to ensure the safety of” Source location 2019-0133-Response-by-Oxford-Health-NHS-Trust
Open published response
9 May 2018 Lewis Daryl COLGAN · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 8 Failure to ensure knowledge and consistent application of the current CPA meeting frequency policy View source Failure to include ongoing action to engage the care coordinator in addressing investigation issues View source Lack of robust supervision within and across care teams, particularly of care coordinator roles and caseloads View source Failure to maintain continuity of engagement and care during key staff changes and sickness absence View source Lack of a robust process for alerting care teams to overdue CPA meetings View source Failure to include the responsible care coordinator in the investigation View source Lack of a proactive approach to scheduling CPA meetings View source Failure of the investigation to address staff training concerns 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
Lewis Daryl COLGAN · 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
Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure knowledge and consistent application of the current CPA meeting frequency policy
Wider context from the report “(3) There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these. Evidence given during the Inquest from different Trust witnesses appeared to identify a difference of opinion as regards what the policy was for frequency of CPA meetings. A concern exists regarding knowledge of what the current policy is and how it is being applied .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include ongoing action to engage the care coordinator in addressing investigation issues
Wider context from the report “(4) Whilst a Root Cause Analysis had been undertaken and a report provided, there were concerns raised during the Inquest with regard to staff training, which the report did not address, and the last care coordinator with conduct of Lewis’ case was not able to participate in the investigation, nor the Inquest. The report did not include an ongoing action to engage with that care coordinator in order to fully address the issues raised in that investigation . As a result, there remains an ongoing concern about the robustness of the investigation and actions identified.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust supervision within and across care teams, particularly of care coordinator roles and caseloads
Wider context from the report “(1) It was clear from the evidence that the role of the care coordinator is very important in terms of engagement with patients, conducting risk assessments, coordinating necessary or periodic meetings and providing regular input to the care team. In Lewis’ case the evidence indicated that the last care coordinator with conduct of his case had not received supervision, that the caseload was, for a period, incompatible with part time working, and that the frequency of engagement with Lewis had reduced compared with what had occurred in previous years. There were also concerns about upward supervision of the care team during this period. Whilst evidence was given that the supervision arrangements are being addressed, there remain concerns that supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuity of engagement and care during key staff changes and sickness absence
Wider context from the report “(2) Lewis’ mental health care revealed issues with regard to management of staff changes and sickness and particularly coordination of continuity of engagement and care in the context of Lewis’ care plan in the absence of key participants in his care on long term sick leave , notably the roles of care coordinator and psychologist and, notwithstanding evidence indicating steps being taken to address staffing issues, there remains a concern that , given the personal nature of the mental health care provided to individuals and the significance of regular engagement with specific individuals, that provision of care in compliance with specified care plans may be compromised .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for alerting care teams to overdue CPA meetings
Wider context from the report “(3) There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these. Evidence given during the Inquest from different Trust witnesses appeared to identify a difference of opinion as regards what the policy was for frequency of CPA meetings. A concern exists regarding knowledge of what the current policy is and how it is being applied.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include the responsible care coordinator in the investigation
Wider context from the report “(4) Whilst a Root Cause Analysis had been undertaken and a report provided, there were concerns raised during the Inquest with regard to staff training, which the report did not address, and the last care coordinator with conduct of Lewis’ case was not able to participate in the investigation, nor the Inquest . The report did not include an ongoing action to engage with that care coordinator in order to fully address the issues raised in that investigation. As a result, there remains an ongoing concern about the robustness of the investigation and actions identified.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a proactive approach to scheduling CPA meetings
Wider context from the report “(3) There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these . Evidence given during the Inquest from different Trust witnesses appeared to identify a difference of opinion as regards what the policy was for frequency of CPA meetings. A concern exists regarding knowledge of what the current policy is and how it is being applied.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the investigation to address staff training concerns
Wider context from the report “(4) Whilst a Root Cause Analysis had been undertaken and a report provided, there were concerns raised during the Inquest with regard to staff training, which the report did not address , and the last care coordinator with conduct of Lewis’ case was not able to participate in the investigation, nor the Inquest. The report did not include an ongoing action to engage with that care coordinator in order to fully address the issues raised in that investigation. As a result, there remains an ongoing concern about the robustness of the investigation and actions identified.
” Open source report
4 Sep 2017 Liam Thomas · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 4 Failure to communicate elevated risk information from staff to family members View source Failure to carry out environmental safety checks at the required frequency View source Failure to obtain relevant information from family for staff View source Failure to prevent access to plastic bags as restricted items on the ward View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liam Thomas · 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
Liam Thomas died on 28 August 2016 after being found in a shower room at Littlemore Hospital with plastic bags over his head; he was pronounced dead at hospital, and the cause of death was asphyxiation. The principal concerns were access to plastic bags and other items posing a personal risk, the effectiveness of environmental safety checks, and communication between hospital staff and Liam’s family about information and elevated 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate elevated risk information from staff to family members
Wider context from the report “The second area of concern is about communication with family. Again, I realise that this is not a straightforward matter because there are issues of consent and it is also the case that some families are not supportive or united. However, in Liam’s case, it is clear that his family were very supportive and united in terms of Liam’s health and wellbeing. A concern at inquest from the evidence was that there was a need for improved communication in terms of information provided by family to staff and also from the staff (particularly concerning elevated risk) to family members . This will enable family to be more watchful . ████████ in her evidence, referred to the “triangular approach” and recognised that there was more work to be done in this difficult area. She indicated that work was on going. It would be helpful if you could provide details about the current policy and practice concerning communications with family and if there is a programme in place, to improve it.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out environmental safety checks at the required frequency
Wider context from the report “A related concern was the environmental searches that were intended, amongst other things, to check for plastic bags. I was shown what are referred to as daily environmental safety check lists which include plastic bags/bin liners on them. I had the impression from the evidence that, at the time, these checks were not being carried out as regularly as they should be . Indeed, I see the recommendation 2 on the RCA/Action Plan concerns standardising the frequency of environmental checks and monitoring of banned items across all in patient wards. It states that they should be carried out daily. It appears a policy is in place and a recommendation but it is not clear to me whether there is effective implementation . Consequently I request that this matter be reviewed and that I receive a response specifically about implementation.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant information from family for staff
Wider context from the report “The second area of concern is about communication with family. Again, I realise that this is not a straightforward matter because there are issues of consent and it is also the case that some families are not supportive or united. However, in Liam’s case, it is clear that his family were very supportive and united in terms of Liam’s health and wellbeing. A concern at inquest from the evidence was that there was a need for improved communication in terms of information provided by family to staff and also from the staff (particularly concerning elevated risk) to family members. This will enable family to be more watchful. ████████ in her evidence, referred to the “triangular approach” and recognised that there was more work to be done in this difficult area. She indicated that work was on going. It would be helpful if you could provide details about the current policy and practice concerning communications with family and if there is a programme in place, to improve it.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent access to plastic bags as restricted items on the ward
Wider context from the report “In relation to the first concern, about plastic bags as restricted items on the ward , the sad fact is that Liam was able to take his own life because he had access to plastic bags . They were Sainsbury’s bags. He attended Sainsbury’s on Section 17 leave two days prior to his death. There was evidence that these bags were taken from him on return to the ward. It could not be ascertained if this was correct and whether the bags which Liam used were bags which he obtained on the trip to Sainsbury’s or whether the bags were obtained in some other way on the ward. I understand there have been improvements in the system in relation to plastic bags in particular. I appreciate however that the problem of plastic bags is not straight forward, particularly when one takes into account the fact that many patients are informal patients and are free to leave and return and that visitors may also bring plastic bags when visiting. I understand that there are clear warnings that plastic bags are restricted items at the entrance to the ward and that steps are taken to bring this to the attention of visitors. It would be helpful if I could be provided with further details about the steps that are in place.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ a full-time Patient and Carer Experience lead to oversee carer and family experience surveys.
Verbatim wording from the response “We have also employed a full time Patient and Carer Experience lead, who is overseeing the Carer and Family surveys which we co-designed with carers, and which provide direct feedback to wards and community teams about the experience of carers and families, and gives teams the opportunity to liaise directly with carers about the improvements they are making.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use co-designed carer and family surveys to provide feedback to wards and community teams and support direct liaison with carers.
Verbatim wording from the response “We have also employed a full time Patient and Carer Experience lead, who is overseeing the Carer and Family surveys which we co-designed with carers, and which provide direct feedback to wards and community teams about the experience of carers and families, and gives teams the opportunity to liaise directly with carers about the improvements they are making.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial alternative environmental-check forms to support staff in completing and recording checks.
Verbatim wording from the response “In addition we are currently trialing several different versions of the form to ensure that it supports staff fully in carrying out this important task. We expect to make a final decision on a form to be used by all by end of October 2017.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and enforce guidance requiring staff to remove plastic bags at reception or supervise their removal and disposal.
Verbatim wording from the response “Plastic bags are a restricted item on all wards. There are posters displaying this in the ward reception areas, and on several points inside the wards. Staff are requested to draw all visitors and patients attention to this and to remove any restricted items before anyone enters the ward environment. Plastic bags are a very common item, and are regularly brought to the ward. Mr Thomas’ sad death drew our attention to the fact that there had been an inconsistent approach to managing this across our wards. Some staff were removing the bags at reception, but at other times visitors (especially regular visitors) were asked to take the items to the patient’s room and then return the bag to the nursing office, but there was no way of checking if this had been done. Following this incident clear guidance was issued to” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add restricted-item advice to admission packs and staff checklists, with monthly matron audits.
Verbatim wording from the response “The advice on restricted items on wards has also been added to the Admission Information packs, and included on the admission check list for staff to complete. Admission checklists are audited by the ward matrons on a monthly basis.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record restricted-item advice and handover confirmations in visitors’ signing-in books and monitor completion weekly.
Verbatim wording from the response “We have added a column to the visitors’ signing in book for staff to confirm that all visitors and returning patients have been advised about restricted items and asked to hand over any such items they may be bringing on to the ward. Staff will be required to complete this, which will be monitored by matrons weekly by checking the visitor’s book, at the same time as the monitoring of environmental checks.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide paper bags on wards as a safe alternative for transporting items.
Verbatim wording from the response “In addition, we looked at alternative safe ways for patients and visitors to bring items on to the wards, and ordered paper bags to be available on all wards as an alternative to carrying items in plastic bags. Staff will offer this as an alternative to visitors at the reception area, and for patients who bring back items when they enter the ward.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standard operating procedure and weekly management review for recording daily environmental checks.
Verbatim wording from the response “A new standard operating procedure (SOP) for carrying out environmental checks was devised and an example of the form is included at appendix 1.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a final decision on the environmental-check form for use across all wards by the end of October 2017.
Verbatim wording from the response “In addition we are currently trialing several different versions of the form to ensure that it supports staff fully in carrying out this important task. We expect to make a final decision on a form to be used by all by end of October 2017.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce IWantGreatCare across online and paper channels to collect patient and carer experience feedback.
Verbatim wording from the response “Earlier this year we introduced a new tool called IWantGreatCare which asks patients and carers a series of questions about their experience of the care they have received and give them opportunity to leave free text feedback. This is immediately received by team managers so they can respond dynamically to concerns raised. The tool is available online and on paper, and we rely on staff on wards and in community teams to ask patients and carers to give feedback, as well as posters and materials in wards and outpatient clinics advertising the feedback tool. In addition our patient and carer engagement lead regularly visits all services to work with managers to ensure plans are in place to address the feedback teams receive and hold open surgeries in wards and outpatient clinics encouraging patients and carers to give feedback.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust does not record every item entering or leaving patient lockers because doing so would be extremely labour intensive.
Verbatim wording from the response “I note that, in your covering letter to the Regulation 28 report, you also raised queries regarding the processes surrounding the removal and return of risk items from patients, for example at times of heightened risk. Specifically you enquired whether it is recorded when items are removed from or returned to patients. Patients may access their secure lockers on a frequent basis throughout the day, and are always observed by staff when doing so, recording all items going in and out of lockers would be extremely labour intensive, however when banned items are found and removed from patients this is recorded in their clinical notes.” Source location 2017-0347-Response-by-Oxford-Health-NHS-Trust
Open published response
21 Feb 2017 JACK OLIVER PORTLAND · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 16 Failure of communication between healthcare staff and prison staff about healthcare records View source Failure to complete timely and accurate Root Cause Analysis reports View source Failure to establish and communicate a clear AWOL and leave authorisation procedure View source Failure to disclose contemporaneous RCA information View source Inadequate communication with families during the ACCT process View source Failure to obtain and update patients’ risk history and assessment View source Insufficient detail in ACCT caremaps and post-closure reviews View source Failure to complete leave observation charts contemporaneously and consistently View source Failure to maintain an accurate and reliable leave tracking system View source Failure to implement changes with clear timescales and adequate coverage of identified concerns View source Delays in identifying relevant witnesses and providing witness statements for coronial investigations View source Failure to coordinate complete and appropriately recorded disclosure for coronial investigations View source Failure to maintain contemporaneous records of AWOL actions View source Delays in completing ACCT post-closure reviews View source Failure to provide S17 leave records to required recipients View source Failure to adequately assess and manage discharge needs of vulnerable prisoners View source See 13 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
JACK OLIVER PORTLAND · 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
Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.
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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between healthcare staff and prison staff about healthcare records
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so , notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete timely and accurate Root Cause Analysis reports
Wider context from the report “(5) The actions taken in relation to the preparation of two Root Cause Analysis reports were of concern in that the first RCA was founded on inaccurate information and the second RCA still contained inaccuracies and was not completed until some 11 months after the fatal event . The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports . The recommendations of the second RCA indicate reviews to be conducted by February/March 2017 but do not appear to address more urgent practical action or possible staff training needs.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and communicate a clear AWOL and leave authorisation procedure
Wider context from the report “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave . There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose contemporaneous RCA information
Wider context from the report “(6) Disclosure, initially to the Coroner, of contemporaneous interviews and information gathered during the early stages of the first RCA may have assisted in preventing subsequent delays and progressing the inquest process, enabling learning from any identified concerns to have been addressed at an earlier stage. In any event such notes and related documents did not form part of the disclosure .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with families during the ACCT process
Wider context from the report “(2) The standard letter notifying a family of the opening of an ACCT was non-specific and dependent upon prisoner consent , yet it was identified that the engagement of families in the ACCT process was important, particularly in the context of risk assessment . It appeared that the same letter is still in use, directing families to telephone extensions for prison staff and healthcare or a 24-hour help line. The family evidence was that communication with the prison in response to a letter received during the first ACCT was of significant concern and that they were not notified of the second ACCT. There was evidence suggesting that the helpline is now attended regularly and messages dealt with but the overall communication paths appear to remain the same .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and update patients’ risk history and assessment
Wider context from the report “(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in ACCT caremaps and post-closure reviews
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review , late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete leave observation charts contemporaneously and consistently
Wider context from the report “(3) The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and reliable leave tracking system
Wider context from the report “(2) A specific request for leave from the patient would be actioned by a nursing-level assessment, authorisation of the specific leave by the nurse in charge and implementation of the leave by a staff member. A Record of Leave of Absence would be completed and signed by the patient and the staff member and that staff member would usually then write up that patient’s name and the times out and due back on a whiteboard in the office. Evidence from witnesses confirmed that there was no particular order to the whiteboard . In the case of Mr Portland, his final leave had not been written on the whiteboard correctly and his absence was not identified until well over an hour after he was due back . The evidence indicated that the whiteboard is still used in the same way , notwithstanding that it was acknowledged that there was scope for human error and that addressing the issue was a matter of urgency.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement changes with clear timescales and adequate coverage of identified concerns
Wider context from the report “(7) Whilst there were indications that there were changes being implemented, there was no clear indication of timescales nor did they address the particular concerns identified during this investigation .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying relevant witnesses and providing witness statements for coronial investigations
Wider context from the report “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate complete and appropriately recorded disclosure for coronial investigations
Wider context from the report “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department . Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure . Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous records of AWOL actions
Wider context from the report “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL .
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing ACCT post-closure reviews
Wider context from the report “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review , communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide S17 leave records to required recipients
Wider context from the report “(1) The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also to the family of a patient along with the Inpatient clinical team and the MHA administrator . The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr Portland’s S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient . The family were unaware of changes to leave and were unable to participate in the leave process or assist Whiteleaf with regard to any heightened risks.
” 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 Oxford Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess and manage discharge needs of vulnerable prisoners
Wider context from the report “(3) There were concerns about the assessment and management of Mr Portland’s discharge needs from admission, particularly with regard to post-release accommodation and positive identification of registration with a GP , given that Mr Portland was homeless and that aftercare ultimately would be dependent upon GP engagement. It was accepted that it is mandatory for prisoner discharges to be undertaken in accordance with the relevant Prison Service Instruction and Early Days and Discharge Specification with all that those encompass. There remains a concern regarding the discharge of prisoners presenting with issues such as those of Mr Portland – a risk of self-harm, substance addiction, homelessness, resolving substance-induced psychosis, vulnerability .
” 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 Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.
Verbatim wording from the response “In addition, a new standard operating procedure (SOP) for managing leave (appendix 1) includes the need for staff to have a discussion with the family, where appropriate consent is given by the patient, regarding the patient’s leave from the ward and to do this every time there is a change to the leave agreed.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review RCA investigator training and develop an additional module on involving and working with families.
Verbatim wording from the response “- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017).
- The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017).
- New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017).
- The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a standard requiring all investigators to complete refresher RCA training at least every three years.
Verbatim wording from the response “- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017).
- The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017).
- New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017).
- The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Survey RCA investigators to assess whether training changes meet their needs.
Verbatim wording from the response “- A survey commenced of RCA investigators in August 2016 to ensure changes in training meets their needs.
- The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require hourly physical handover of observation charts, with both allocated staff checking that records are complete and accurate.
Verbatim wording from the response “The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require shift coordinators to sign off relevant observation and leave-record sheets before handover.
Verbatim wording from the response “An existing SOP which covers shift co-ordination has had a new action added, which is that the shift co-ordinator signs off all relevant sheets, including observation charts, to ensure that all staff have fully completed the required paperwork, including the leave record form, and it is in order before handing over to the next shift.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor RCA investigation allocation, progress and timeliness weekly, with quarterly reporting to the Board of Directors.
Verbatim wording from the response “- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016.
- The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016.
- Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace multiple leave-recording locations and the whiteboard with one central ward document.
Verbatim wording from the response “The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an external review of the quality of serious-incident investigations to identify improvements.
Verbatim wording from the response “- A survey commenced of RCA investigators in August 2016 to ensure changes in training meets their needs.
- The Trust commissioned an external review of the quality of SI investigations completed in November 2016 to help the Trust to identify where and how to improve.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the revised RCA training, including the additional family-involvement module.
Verbatim wording from the response “- A review of RCA training for investigators, including an additional module on involving and working with families during an investigation (Lead: ████████. Timescale: new training to be delivered from 30th June 2017).
- The introduction of a new standard that all investigators will complete refresher RCA training at least every 3 years (Lead: ████████. Timescale: from 1st Nov 2017).
- New staff and family information leaflets to describe the RCA investigation process, standards and what families can expect with central senior contact points for further support as needed are currently being developed (Lead: ████████. Timescale: introduced from 1st July 2017).
- The second RCA investigation relating to Mr Portland’s case is to be amended to include the additional concerns arising at inquest and actions will be added to the action plan (Lead: ████████. Timescale: 30th April 2017).” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate AWOL procedures to staff and provide guidance and Missing Patient Action Checklists on all acute inpatient wards.
Verbatim wording from the response “The responsibility for ensuring that patients are back from leave now clearly rests with the person allocated to carry out general observations. That staff member is also responsible for informing the shift co-ordinator, who will co-ordinate the implementation of the AWOL policy, if a patient does not return on time (appendix 3). The shift co-ordinator is always a qualified nurse.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.
Verbatim wording from the response “Staff have been strongly reminded that it is not appropriate to fill in observations paperwork prospectively or retrospectively. This is now monitored by the Matron. We are in the process of reviewing the Trust’s Observation Policy, and will ensure that this is also made very explicit within the new version. This policy review will be complete by the end of April 2017.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated full-time RCA investigator capacity in the adult mental health directorate.
Verbatim wording from the response “- A series of training sessions were held on promoting the status of families in investigations, ensuring they are central to the process (“Making Families Count”), which were co-delivered with the charity Hundred Families in May and June 2016.
- The Trust has improved its capacity for completing comprehensive and timely investigations, including appointment of a dedicated, full time post of RCA investigator/author in the adult mental health directorate. This person was appointed in February 2016.
- Weekly monitoring processes were introduced from July 2016 to better identify the right investigators, timely allocation of investigators and review of the progress of investigations. We now report on the timeliness of RCA investigations on a weekly basis to the Executive Team and quarterly to the Board of Directors.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.
Verbatim wording from the response “The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providing patients or families copies of leave forms is not mandatory under the Mental Health Act Code of Practice or Trust policy.
Verbatim wording from the response “The provision of copies of leave forms is not in fact mandatory under either the Mental Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which suggests that this is the case, is misleading). Nevertheless, it is acknowledged that in many cases patients and their families find it useful to have a copy of the form in addition to being involved in discussions around the granting of any leave and conditions. The section 17 leave form has been amended and is currently going through the Trust’s governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017. The newly designed form allows the consultant to indicate, following discussions with patients and families, if copies should be provided and, if so, to whom.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The second RCA did not need to revisit immediate actions because the initial review had already identified them and the actions required.
Verbatim wording from the response “An initial review is completed for every serious incident, as was the case following Mr Portland’s death. Each initial review report should be completed within 5 days of the incident/death, reviewed by the senior clinical team and also by a weekly Trust wide executive meeting. The purpose of the initial review report is to set out the initial facts known, to identify any immediate action or learning required and to help develop the scope for the RCA investigation. The initial review report into Mr Portland’s death identified three immediate actions all around the timeliness of initiating the AWOL procedure. The initial review report was shared with the CQC.” Source location 2017-0049-Response-by-Oxford-Health-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations