21 May 2026 George Edward James Haldenby · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision View source Incomplete availability of critical medications held in prison View source Lack of local policy or process for managing out-of-hours FP10 prescriptions View source Lack of mandatory refresher training in first aid and CPR for prison staff View source See 1 more concern
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AI-generated summary
George Edward James Haldenby · 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
George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision
Wider context from the report “In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse , and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete availability of critical medications held in prison
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy or process for managing out-of-hours FP10 prescriptions
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory refresher training in first aid and CPR for prison staff
Wider context from the report “After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR . During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR , there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur.
” 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 Implement the Southwest Out of Hours SOP for sourcing prescribed medicines outside normal operating hours.
Verbatim wording from the response “Following a review of these concerns, we can confirm that a formal process has been in place across the Southwest region since September 2024 through the implementation of the Southwest Out of Hours Standard Operating Procedure (SOP)- (Appendices 1). This SOP was circulated to all relevant healthcare teams upon implementation and remains accessible through the organisational document management systems, including the Ox and the SystmOne Pharmacy Document Library.” Source location 2026-0312 - Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recirculate the Southwest Out of Hours SOP and associated guidance to all healthcare teams.
Verbatim wording from the response “In addition, this incident has provided an opportunity to further reinforce awareness of existing medicines management policies and SOPs. The Southwest Out of Hours SOP and associated guidance will be recirculated to all healthcare teams, and ongoing training sessions will continue to reinforce staff understanding and compliance. The Medicines Management SOP Log will also be redistributed to all Heads of Healthcare to improve visibility of current medicines-related procedures, alongside signposting staff to the centrally maintained document repository where the most up-to-date versions are held.” Source location 2026-0312 - Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue training sessions reinforcing staff understanding and compliance with medicines management policies and SOPs.
Verbatim wording from the response “In addition, this incident has provided an opportunity to further reinforce awareness of existing medicines management policies and SOPs. The Southwest Out of Hours SOP and associated guidance will be recirculated to all healthcare teams, and ongoing training sessions will continue to reinforce staff understanding and compliance. The Medicines Management SOP Log will also be redistributed to all Heads of Healthcare to improve visibility of current medicines-related procedures, alongside signposting staff to the centrally maintained document repository where the most up-to-date versions are held.” Source location 2026-0312 - Response from Oxleas NHS Foundation 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 Existing governance and operational guidance address the concerns about obtaining prescribed medication outside normal working hours.
Verbatim wording from the response “Following a review of these concerns, we can confirm that a formal process has been in place across the Southwest region since September 2024 through the implementation of the Southwest Out of Hours Standard Operating Procedure (SOP)- (Appendices 1). This SOP was circulated to all relevant healthcare teams upon implementation and remains accessible through the organisational document management systems, including the Ox and the SystmOne Pharmacy Document Library.” Source location 2026-0312 - Response from Oxleas NHS Foundation 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 Heads of Healthcare, supported by local Medicines Management teams, are responsible for implementing centrally developed medicines-management policies and procedures.
Verbatim wording from the response “Whilst these SOPs and policies are developed and maintained centrally, responsibility for local implementation rests with Heads of Healthcare, supported by local Medicines Management teams. They are responsible for ensuring that all relevant staff are familiar with, acknowledge, and adhere to the requirements set out within the SOPs and associated policies. Compliance is monitored through established governance processes, and where individuals are identified as persistently deviating from approved procedures, they will be supported and managed in accordance with the Trust's capability and performance management policies. This may” Source location 2026-0312 - Response from Oxleas NHS Foundation Trust
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24 Mar 2026 Thomas Daniel RUGGIERO · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1 Failure to secure attendance of the mental health team at required ACCT reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Revise mental-health staffing rotas to provide skilled practitioners during peak ACCT review periods.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Run a daily multidisciplinary safety huddle to review ACCT patients, prioritise reviews, escalate risks, allocate actions and share information.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Audit healthcare attendance at ACCT reviews and oversee compliance through clinical governance, PSIRF, risk-register and executive assurance arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Introduce an escalation and contingency process for missed healthcare attendance, including senior notification, alternative staffing, documentation and risk mitigation.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Circulate and embed the Kent ACCT Standard Operating Procedure through local induction and mandatory training, including exceptional non-attendance requirements.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Strengthen forward planning for high-risk ACCT cases and monitor healthcare representation through daily operational meetings.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Disseminate learning across offender healthcare through reflective practice sessions reinforcing healthcare input in ACCT processes.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source See 4 more actions
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AI-generated summary
Thomas Daniel RUGGIERO · 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
Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing and died later that day following attempts at treatment and resuscitation. The principal concern was that healthcare or mental health team attendance at ACCT reviews was not consistently secured, creating an ongoing risk for vulnerable prisoners relying on those processes as a safety-net and protective factor.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure attendance of the mental health team at required ACCT reviews
Wider context from the report “(1) There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews. In this case, there were numerous instances that this was not met . While I heard evidence of some improvement, it was accepted that there were ongoing issues with securing the attendance of the mental health team (where required) at ACCT reviews . I was insufficiently reassured that the matter has been addressed and I consider that there is ongoing risk to particularly vulnerable prisoners for whom the ACCT processes should act as a safety-net and protective factor.
” 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 Revise mental-health staffing rotas to provide skilled practitioners during peak ACCT review periods.
Verbatim wording from the response “In December 2024, a review of the mental health staffing model at HMP Swaleside was undertaken to strengthen the service's capacity to consistently attend and contribute to ACCT reviews. This review identified gaps in aligning staff availability with periods of higher ACCT demand. In response, revised rota arrangements were introduced, ensuring that appropriately skilled mental health practitioners are available during peak activity times, particularly during core ACCT review periods. This adjustment has improved responsiveness, reduced delays in attendance, and supported more consistent multidisciplinary input into risk management planning.” Source location Response from Oxleas NHS FT
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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 Run a daily multidisciplinary safety huddle to review ACCT patients, prioritise reviews, escalate risks, allocate actions and share information.
Verbatim wording from the response “In January 2025, a structured daily safety huddle was introduced at HMP Swaleside, providing a formal mechanism for real-time oversight and coordination of high-risk patients. The huddle is held each morning and is attended by key members of the multidisciplinary team, including mental health, primary care, substance misuse, and operational leads where required. During the huddle, the team reviews all patients subject to ACCT, as well as any other individuals identified as presenting an elevated or emerging risk.
The daily huddle includes:” Source location Response from Oxleas NHS FT
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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 Audit healthcare attendance at ACCT reviews and oversee compliance through clinical governance, PSIRF, risk-register and executive assurance arrangements.
Verbatim wording from the response “Healthcare attendance at ACCT reviews is now subject to routine audit, with results reviewed through local clinical governance forums and within the Trust's Patient Safety Incident Response Framework (PSIRF) oversight structures. This is overseen by the head of healthcare and compliance is actively monitored, with any identified gaps followed up through targeted action plans. This area has also been incorporated into the Trust's risk register, with appropriate executive oversight in place.” Source location Response from Oxleas NHS FT
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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 Introduce an escalation and contingency process for missed healthcare attendance, including senior notification, alternative staffing, documentation and risk mitigation.
Verbatim wording from the response “A formalised escalation and contingency process has been introduced to address occasions where healthcare attendance cannot be secured. This requires immediate notification to senior clinical leads, consideration of alternative appropriately qualified staff where feasible, and clear documentation of the rationale for non-attendance, alongside any mitigating actions taken to manage risk.” Source location Response from Oxleas NHS FT
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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 Circulate and embed the Kent ACCT Standard Operating Procedure through local induction and mandatory training, including exceptional non-attendance requirements.
Verbatim wording from the response “In June 2025 the Kent ACCT Standard Operating Procedure was circulated and sets out clear guidance to all healthcare staff to reinforce expectations regarding attendance at ACCT reviews. This includes clarification of when mental health team involvement is required and the actions that must be taken if attendance cannot be achieved. The Standard Operating Procedure reiterates that a telephone or written contribution must be provided in exceptional circumstances when healthcare staff cannot attend. This updated guidance has been embedded within local induction processes and incorporated into mandatory training to support consistent understanding and application.” Source location Response from Oxleas NHS FT
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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 Strengthen forward planning for high-risk ACCT cases and monitor healthcare representation through daily operational meetings.
Verbatim wording from the response “Multi-disciplinary working between healthcare and prison staff has been further strengthened through improved communication arrangements, particularly in relation to the scheduling of ACCT reviews. A daily tracker is circulated each evening by the prison safety team, clearly identifying individuals due for ACCT review the following day, which is then reinforced and actioned through the daily huddles. Any discrepancies are promptly identified and escalated to ensure timely resolution. Enhanced forward planning is now in place for high-risk individuals, and mental health representation at case reviews is actively monitored and supported through daily operational meetings.” Source location Response from Oxleas NHS FT
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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 Disseminate learning across offender healthcare through reflective practice sessions reinforcing healthcare input in ACCT processes.
Verbatim wording from the response “Finally, learning from this case has been disseminated across the Offender healthcare directorate. Reflective practice sessions have been undertaken with clinical teams to reinforce the importance of healthcare input within ACCT processes. Ongoing monitoring arrangements are in place to ensure that these improvements are embedded and sustained overtime.” Source location Response from Oxleas NHS FT
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19 Feb 2026 Rajwinder Singh · Prevention of Future Deaths report Inner West London
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Concerns raised 3 Lack of training in the principles of risk formulation during ACCT induction View source Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment View source Lack of mandatory ACCT refresher training for prison officers 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
Rajwinder Singh · 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
Rajwinder Singh was imprisoned after being sentenced at Southwark Crown Court and was identified as at risk of self-harm and suicide. He was transferred to St George’s Hospital after failures including unanswered cell bells and inadequate observations, and died there on 25th June 2026. The principal concerns included inadequate risk assessment and record keeping, failures in observations and handovers, and insufficient mandatory ACCT training for prison and agency healthcare staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training in the principles of risk formulation during ACCT induction
Wider context from the report “(3) When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
Wider context from the report “(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory ACCT refresher training for prison officers
Wider context from the report “(1) There is no mandatory ACCT refresher training for prison officer at HMP Wandsworth ;
” 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 Make risk-formulation training part of future core training for all staff.
Verbatim wording from the response “A further two-day module will be facilitated by Mindworks on March 5th and 6th and will use a variety of media including a full day of working with an actor to explore the skills required and the detailed practice of risk practice and risk assessment in the management of this vital area. It is planned that this training will form part of our future core training for all staff.” Source location Response from Oxleas NHS
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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 Commission training modules examining self-harm and suicide risk formulation beyond the ACCT process.
Verbatim wording from the response “Oxleas NHS Foundation Trust have recognised that the principles of risk formulation is vital when managing the ACCT process at HMP Wandsworth. We have commissioned a series of training modules to specifically focus on a deeper examination of the risk of self-harm and suicide in the prison population, beyond the ACCT process. Healthcare staff and prison officer colleagues have been invited to attend this non mandatory training.” Source location Response from Oxleas NHS
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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 Require temporary healthcare staff to complete ACCT training before deployment and record attendance.
Verbatim wording from the response “It is now mandatory for all temporary healthcare staff to undertake ACCT training. This training is currently provided by the Oxleas NHS Foundation Trust Practice Development Nurse (PDN). Attendance” Source location Response from Oxleas NHS
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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 Facilitate a two-day Mindworks module developing risk-practice and risk-assessment skills for managing self-harm and suicide risk.
Verbatim wording from the response “A further two-day module will be facilitated by Mindworks on March 5th and 6th and will use a variety of media including a full day of working with an actor to explore the skills required and the detailed practice of risk practice and risk assessment in the management of this vital area. It is planned that this training will form part of our future core training for all staff.” Source location Response from Oxleas NHS
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29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
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Concerns raised 3 Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings View source Failure to establish prison healthcare capability to replicate ambulance-service emergency skills View source Lack of cross-party dialogue and learning from serious medical emergencies 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
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after an episode of self-strangulation in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrest during conveyance to hospital. The substantive concerns included disproportionate and prolonged restraint, delays in obtaining healthcare assistance and starting CPR, inadequate communication, and uncertainty about responsibility for acute medical emergencies in custodial settings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
Wider context from the report “(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primary in an acute medical emergency in a custodial 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish prison healthcare capability to replicate ambulance-service emergency skills
Wider context from the report “(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved. Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence. During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting . One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-party dialogue and learning from serious medical emergencies
Wider context from the report “(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved . Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence . During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting. One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service).
” Open source report
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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 Recruit paramedics for HMP Swaleside.
Verbatim wording from the response “A student paramedic placement has been initiated, with SECAMb second student paramedics spending one day at Sheppey prisons to become familiar with the environment. Insights shared during partnership meetings indicated that SECAMb personnel often find the prison setting challenging. Paramedic recruitment is ongoing at HMP Swaleside, and the initial one-day placement will be developed into comprehensive placements for student paramedics.” Source location Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate quarterly partnership meetings to review learning, share training resources, assess prison-based NHS resources, and coordinate major-incident preparedness.
Verbatim wording from the response “The concerns regarding dialogue and partnership working have been addressed. Since 2024, Oxleas, SECAMbs, and HMPPS have established a regular partnership meeting, bringing together leaders from agencies across Medway and Swale on a quarterly basis. The primary objectives of this collaboration are to review joint learning opportunities, share training resources, assess the impact of community NHS resources within the prison environment, and coordinate efforts to prepare for potential major incidents. The suggestion that prison healthcare staff could undertake the role of the ambulance service was not supported as this model is not in line with national commissioning policy however the underlying concerns regarding difficulties related to medical emergencies has been central to the partnership working and collaboration that has taken place.” Source location Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Jointly draft a memorandum of understanding defining agencies’ responsibilities and coordinating joint working during major incidents.
Verbatim wording from the response “As part of this collaboration, bronze, silver, and gold command training is being incorporated into the Oxleas service and is currently in the process of being sourced appropriately. Additionally, a memorandum of understanding is being jointly drafted by HMPPS, Kent Fire and Rescue, Oxleas, and SECAMbs to outline each agency's responsibilities and to facilitate coordinated joint working during major incidents.” Source location Response from Oxleas NHS Foundation 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 Existing arrangements establish Oxleas’ responsibility and leadership for acute medical emergencies, with paramedics supporting Oxleas staff when required.
Verbatim wording from the response “It is recognised that in this very sad incident there may have been confusion regarding primacy in a medical emergency. This incident pre-dates Oxleas NHS Foundation Trust’s delivery of healthcare services at HMP Elmley. The Trust is clear that, as the primary healthcare provider at HMP Elmley, Oxleas NHS Foundation Trust retains responsibility for the care and treatment of prisoners until their departure from custody, regardless of whether this occurs via ambulance or other means, including primacy in an acute medical emergency. There is an inpatient healthcare team at HMP Elmley and staff attend and lead healthcare emergencies as normal practice. Where paramedic support is required, our staff work with paramedics to ensure that their skills are deployed in partnership with the Oxleas staff during the incident.” Source location Response from Oxleas NHS Foundation 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 Prison healthcare staff will not undertake the ambulance service’s role because that model is not in line with national commissioning policy.
Verbatim wording from the response “The concerns regarding dialogue and partnership working have been addressed. Since 2024, Oxleas, SECAMbs, and HMPPS have established a regular partnership meeting, bringing together leaders from agencies across Medway and Swale on a quarterly basis. The primary objectives of this collaboration are to review joint learning opportunities, share training resources, assess the impact of community NHS resources within the prison environment, and coordinate efforts to prepare for potential major incidents. The suggestion that prison healthcare staff could undertake the role of the ambulance service was not supported as this model is not in line with national commissioning policy however the underlying concerns regarding difficulties related to medical emergencies has been central to the partnership working and collaboration that has taken place.” Source location Response from Oxleas NHS Foundation Trust
Open published response
25 Jul 2025 Sheldon Lawrence Jeans · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol View source Failure to secure in-possession medication against access by other prisoners View source Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons View source Failure to ensure return of excess medication after prescription discontinuation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sheldon Lawrence Jeans · 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
On 13 November 2022, Sheldon Lawrence Jeans, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell. The inquest recorded that he died following an idiosyncratic response to alcoholic intoxication and medicinal drugs, combined with partial postural asphyxia. The report raised concerns about the lack of guidance on illicitly brewed alcohol and the governance, storage and return of medication held by prisoners.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure in-possession medication against access by other prisoners
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication, could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure return of excess medication after prescription discontinuation
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication , could lead to future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and distribute prison health-promotion materials on safe medication storage and disposal of unused or discontinued medication.
Verbatim wording from the response “To further support safe medication practices, we will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh, but also within the wider Oxleas NHS Foundation Trust prison portfolio. These materials will focus on:” Source location Response from Oxleas 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 Remove medications that could assist illicit alcohol production from the formulary or provide them only under supervised, not-in-possession arrangements.
Verbatim wording from the response “There are many ways in which alcohol can be illicitly brewed in the prison setting. It is known that certain prescribed medications could be used to assist in the fermenting process and, where possible, we have already removed these from the prescribing formulary or” Source location Response from Oxleas 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 Implement a published in-possession medication compliance procedure with bi-monthly in-cell checks, discrepancy escalation and documented oversight.
Verbatim wording from the response “There is no national policy around the governance of medication held in possession in the prison estate. Attached is our recently published local In-possession Medication Compliance procedure which outlines bi-monthly in-cell compliance checks for patients on in-possession medication. This process, which is led by pharmacy staff with HMPPS support, checks to ensure medication adherence, prevent diversion, and upholds the safety of medication. Any discrepancies would trigger a review, disciplinary action, or changes to in-possession status. Documentation is maintained via SystmOne. If required, formal notification letters are sent to the patients. The procedure aligns with NICE and Royal Pharmaceutical Society guidelines. Oversight is shared between pharmacy, wider healthcare and HMPPS teams and ensures that there are robust assurance mechanisms in place.” Source location Response from Oxleas 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 Assess medication and individual suitability before issuing in-possession medication, with reassessment when circumstances change.
Verbatim wording from the response “Before any medication is issued in-possession, a comprehensive risk assessment is undertaken to evaluate both the medication(s) and the individual’s suitability. This risk assessment can be updated / changed at any time but particularly in the event of a change of an individual’s circumstances.” Source location Response from Oxleas 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 Conduct intelligence-led and random checks of in-possession medication to monitor compliance and safety.
Verbatim wording from the response “Healthcare teams conduct intelligence-led and random in-possession checks to monitor compliance and safety. Nonetheless, the overall security of the prison environment,” Source location Response from Oxleas 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 Existing risk assessments, compliance checks and medication procedures provide robust safeguards for in-possession medication governance.
Verbatim wording from the response “The practice of allowing prisoners to hold certain medications in-possession is designed to promote personal responsibility and mirror community standards. This approach supports individuals in preparing for release and reintegration with the community and aligns with the principle of equivalence of care. It is also in line with a variety of nationally applicable guidance. https://www.rpharms.com/recognition/setting-professional-standards/optimising-medicines-in-secure-environments.” Source location Response from Oxleas 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 HMPPS is responsible for prison security and safeguarding medication, including personal lockable safes for storage.
Verbatim wording from the response “including the safeguarding of medication, is the responsibility of His Majesty’s Prison and Probation Service (HMPPS). We work closely with HMPPS to ensure that security protocols are upheld and adapted as needed. This also includes the supervision of not-in-possession medication provided by Prison staff at the medication hatches.” Source location Response from Oxleas NHS Foundation Trust
Open published response
18 Jul 2025 Patryk Gladysz · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Out-of-date First Aid refresher training for healthcare staff View source Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness View source Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS View source Ongoing challenges in prison officer checks of roll calls and ACCT observations View source Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments View source Deactivation of healthcare staff NOMIS accounts due to lack of use View source Lack of prison staff knowledge of the heightened risk of foreign nationals in custody View source Staffing levels diluting key worker scheme requirements View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patryk Gladysz · 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
Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Out-of-date First Aid refresher training for healthcare staff
Wider context from the report “(6) First Aid refresher training is not up to date for all healthcare staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia ; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff ; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ongoing challenges in prison officer checks of roll calls and ACCT observations
Wider context from the report “(5) Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments
Wider context from the report “(1) Staffing within the Mental Health in-reach team impacting the timely undertaking of meaningful and quality mental health assessments .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deactivation of healthcare staff NOMIS accounts due to lack of use
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff knowledge of the heightened risk of foreign nationals in custody
Wider context from the report “(3) Knowledge of prison staff of the heightened risk of foreign nationals in custody , despite a higher proportion of foreign nationals being detained at HMP Wandsworth.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Staffing levels diluting key worker scheme requirements
Wider context from the report “(2) Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme .
” 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 Use bank or agency staff to fill vacant mental health service posts during recruitment.
Verbatim wording from the response “Oxleas NHS Foundation Trust are supported with a proactive temporary staffing team, and we endeavour to fill vacant posts within this service with bank or agency staff during the recruitment process.” Source location Response from NHS England
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 NOMIS training and support to the practice development nurse, new users and existing users requiring assistance.
Verbatim wording from the response “All members of healthcare are expected to have an activated NOMIS account. Staff with deactivated accounts have been requested to be reinstated. There is no confirmed date for reactivation; however, confirmation has been received that the accounts of those still employed by the Trust have been reactivated. The practice development nurse (PDN) and team leader have been working with staff since the beginning of August, and it is anticipated that all staff will have access to NOMIS and be able to demonstrate this to their line manager before 15 October 2025. A record of this is being maintained and will continue to be monitored. Training and support on the use of NOMIS have been provided to the PDN and will be available to all new users and to existing users where support is required.” Source location Response from NHS England
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 Recruit vacant mental health in-reach nursing posts following the successful recruitment campaign.
Verbatim wording from the response “The permanent fill rate of the in reach mental health nursing team between April 2023 and January 2024 was 33 % and 67% respectively. The current permanent fill rate of the mental health in reach nursing team is 67% and following a successful recruitment campaign these vacancies are currently being recruited to, and we anticipate a start date to be soon.” Source location Response from NHS England
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 Reinstate and enable NOMIS access for healthcare staff, with access demonstrations recorded and monitored.
Verbatim wording from the response “All members of healthcare are expected to have an activated NOMIS account. Staff with deactivated accounts have been requested to be reinstated. There is no confirmed date for reactivation; however, confirmation has been received that the accounts of those still employed by the Trust have been reactivated. The practice development nurse (PDN) and team leader have been working with staff since the beginning of August, and it is anticipated that all staff will have access to NOMIS and be able to demonstrate this to their line manager before 15 October 2025. A record of this is being maintained and will continue to be monitored. Training and support on the use of NOMIS have been provided to the PDN and will be available to all new users and to existing users where support is required.” Source location Response from NHS England
Open published response
13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
View report summary
Concerns raised 12 Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits View source Failure to direct staff to the need for 1:1 monitoring View source Failure to apply A&E risk assessment and staffing policies to mental health staff View source Absence of audit of absconsions and mental health liaison in A&E View source Failure to recognise high-risk mental health patients View source Incorrect understanding of Mental Health Act assessment criteria View source Failure to acknowledge communicated patient risk View source Failure to complete required duplicate A&E clinical record entries by mental health staff View source Lack of shared access to mental health and A&E clinical records View source Failure to document mental health assessments when no recording location is available View source Inconsistent risk assessment documentation and training across departments View source Gaps in mental health professionals’ knowledge and clinical judgment View source See 9 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
Mr Paul Timothy Dunne · 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
Mr Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to direct staff to the need for 1:1 monitoring
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need . When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply A&E risk assessment and staffing policies to mental health staff
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of audit of absconsions and mental health liaison in A&E
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise high-risk mental health patients
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk , despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect understanding of Mental Health Act assessment criteria
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge communicated patient risk
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required duplicate A&E clinical record entries by mental health staff
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records. MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared access to mental health and A&E clinical records
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records . MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document mental health assessments when no recording location is available
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment , as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent risk assessment documentation and training across departments
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Gaps in mental health professionals’ knowledge and clinical judgment
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report
19 Jul 2024 Benjamin Noah Frances Harrison · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 7 Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011 View source Lack of a clear process for sharing and recording healthcare information View source Lack of guidance for escalating and monitoring suspected intoxication View source Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication View source Failure to promptly notify the prison orderly and document suspected intoxication View source Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence View source Failure to brief prison staff about prisoners with medication in possession View source See 4 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
Benjamin Noah Frances Harrison · 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
Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011
Wider context from the report “(3) In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared .
Some healthcare staff in evidence indicated they would not share information about medication in any circumstances .
The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner's consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm.
There was no clear process as to how or where the information would be shared and recorded either where a prisoner had consented to information sharing or where consent had not been given but it was nevertheless necessary to share the information.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for sharing and recording healthcare information
Wider context from the report “(3) In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared.
Some healthcare staff in evidence indicated they would not share information about medication in any circumstances.
The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner's consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm.
There was no clear process as to how or where the information would be shared and recorded either where a prisoner had consented to information sharing or where consent had not been given but it was nevertheless necessary to share the information.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for escalating and monitoring suspected intoxication
Wider context from the report “(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester.
During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state.
OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter.
The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented.
Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
Wider context from the report “(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester.
During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state.
OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter .
The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented.
Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly notify the prison orderly and document suspected intoxication
Wider context from the report “(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester.
During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state.
OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter.
The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented .
Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence
Wider context from the report “(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester.
During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state.
OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter.
The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented.
Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to brief prison staff about prisoners with medication in possession
Wider context from the report “(2) Prison staff did not receive a briefing about prisoners with medication in possession in accordance with PSI24/2011
” 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 Deliver PSI 64/2011 and relevant policy guidance through teaching, read-and-sign procedures, handovers and supervision, with training records retained.
Verbatim wording from the response “3. To support addressing understanding of policies, we have a new Practice Development Nurse (PDN) joining the team in September 2024, to ensure that the healthcare team are up to date with all relevant training and guidance. The PDN will share the clear guidance set out in chapter 2 of PSI 64/2011 and ensure via teaching sessions, read-and-sign procedure and supervision that this guidance is understood and followed by the nursing and wider healthcare team. There are mechanisms in place to share relevant safety and risk information on NOMIS, and this would have included sharing information of the risks of misusing a Fentanyl patch.” Source location Response from Oxleas 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 Update guidance to clarify that required patient monitoring cannot occur without on-site healthcare and requires hospital transfer.
Verbatim wording from the response “We will ensure that this guidance is updated and that it also includes the relevant information to manage the expectations of HMPPS colleagues – for example if any patient monitoring is required then this cannot be undertaken at HMP Rochester when there are no healthcare staff on site and in any circumstances where a patient requires monitoring then they would need to be transferred to hospital.” Source location Response from Oxleas 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 Review, update and disseminate healthcare policies to staff using the latest versions.
Verbatim wording from the response “Our Quality Manager has very recently reviewed all policies, updated them to the latest versions and shared their location with all staff. Our PDN will have the responsibility of ensuring that the healthcare team are aware of all relevant policies, that they understand the policies and the importance of following them, and that these are shared and discussed in teaching sessions, handovers, and supervisions. Training records will be kept in order to evidence this.” Source location Response from Oxleas 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 Introduce a Practice Development Nurse role to support healthcare-team training, guidance and policy compliance.
Verbatim wording from the response “3. To support addressing understanding of policies, we have a new Practice Development Nurse (PDN) joining the team in September 2024, to ensure that the healthcare team are up to date with all relevant training and guidance. The PDN will share the clear guidance set out in chapter 2 of PSI 64/2011 and ensure via teaching sessions, read-and-sign procedure and supervision that this guidance is understood and followed by the nursing and wider healthcare team. There are mechanisms in place to share relevant safety and risk information on NOMIS, and this would have included sharing information of the risks of misusing a Fentanyl patch.” Source location Response from Oxleas 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 Review out-of-hours GP calls to assess their frequency and effectiveness.
Verbatim wording from the response “The agreed arrangements between the hours of 21:00 – 07:30 when there is no commissioned healthcare provision on site, is that all higher risk prisoners have an agreed personal management plan in accordance with the Personal Management Plan Local Operating Procedure, and that in the event that officers have any healthcare concerns regarding a prisoner the Custodial Manager in charge of the prison should call the On-Call GP for further advice and guidance, and in an emergency they should dial 999 for emergency services. A review of out of hours calls to the out of hours GP service will be carried out in Autumn 2024 to ascertain frequency and effectiveness of use. Any calls to out of hours GP are discussed in the Governor’s morning briefing each day and followed up by the healthcare team.” Source location Response from Oxleas 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 Share relevant medication and safety-risk information during weekly Safety Intervention Meetings.
Verbatim wording from the response “This guidance is that the clear verbal briefing should include all prisoners who are ‘at risk’, and not all prisoners. It would not be possible to include all prisoners who have medication in possession in a nightly verbal briefing when up to a third of the total population are prescribed In Possession medication. It would not be practical and could distract from the prisoners who are at risk, and who require inclusion in the clear verbal briefing to ensure safety. We have agreed with prison colleagues that healthcare will share relevant information within the weekly Safety Intervention Meeting and discuss men with in-possession medication who may be at risk, so that prison managers responsible for those individuals are aware of any prescribed medication that may inform any risk management decisions.” Source location Response from Oxleas 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 NHS England is responsible for explaining whether 24-hour healthcare should be commissioned in Category C prisons because of drug-related patient safety risks.
Verbatim wording from the response “such as psychoactive substances ‘spice’ are explored. Change, Grow, Live (CGL) are subcontracted by Oxleas to provide psychosocial substance misuse and they have a large caseload at HMP Rochester who undertake group and 1:1 work to address substance misuse issues including the use of psychoactive substances, and encourage harm minimisation and ultimately recovery. Healthcare attend to those suspected to be under the influence of substances during the day until 21:00 as contracted by NHS England. As a Category C prison, Rochester, in accordance with most Category C prisons does not have 24-hour healthcare provision. The contracts for Category C prisons do not normally make provision for healthcare services at night if there is no Inpatient department, and therefore no prisoners requiring 24-hour healthcare provision.” Source location Response from Oxleas 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 Existing night arrangements, including trained officers, personal management plans, on-call GP advice and emergency services, are relied upon to manage healthcare concerns.
Verbatim wording from the response “OSG officers have undergone basic first aid training during their induction to the standard deemed by HMPPS appropriate for their roles, including being in service during night patrols without healthcare staff on site, and managing any situation which may occur. HMPPS colleagues will be able to give further details regarding this training. The OSGs work together with Orderly Officers who have additional training and experience, and they have operational procedures to follow in the event of prisoners who present as requiring medical support during night state.” Source location Response from Oxleas 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 Patient monitoring cannot be undertaken at night without healthcare staff on site; patients requiring monitoring must instead be transferred to hospital.
Verbatim wording from the response “As stated, there is no in-house healthcare in HMP Rochester after 9pm. There are arrangements for GP on-call provision arranged by providers which we have in place at HMP Rochester. GPs on an on-call rota have access to SystmOne records and therefore access to past medical history, past and current medical problems and any future appointments is in place to provide medical advice to prison staff, prevent unnecessary transfers to hospital and ensure patient safety by providing guidance on next steps when hospital transfer is required.” Source location Response from Oxleas 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 A nightly verbal briefing for all prisoners with medication in possession is considered impractical because they comprise up to one-third of the prison population.
Verbatim wording from the response “2. The guidance states that “during the night state Prisoners who are ‘at risk’ are observed, managed, supported and information and actions are recorded. Night staff must receive a clear verbal briefing on any prisoners who are identified to require a higher level of individual observations than normally required (such as those on an open, or, post closure Assessment Care in Custody and Teamwork (ACCT) plan (check and be directed by individual plans), or other prisoners on a higher than normal observation level for other reasons such as E-List, high security risk, or medication purposes). The briefing should also include information about any prisoner with medication in possession or where healthcare staff will have to administer medicines dose by dose throughout the “Night State”.” Source location Response from Oxleas NHS Foundation Trust
Open published response
4 Mar 2024 Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Failure to consider individual patient applicability when following prescribing guidelines View source Insufficient specialist expertise in prescribing drug treatments for withdrawal View source Failure to withhold or reduce methadone when patients show signs of sedation View source Overreliance on subjective withdrawal symptoms rather than objective signs when assessing methadone need View source Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone View source Unavailability of near-patient illicit-drug testing for assessing intoxication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Deliver case-based learning for prescribers on prioritising objective withdrawal signs over reported symptoms.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Stock and mandate near-patient urine drug testing for patients presenting with sedation of unknown cause, making tests available to clinicians.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Follow national guidance on any revised opiate withdrawal scale and support implementing an approved change.
Stated plannedThe respondent said that this action was planned when they made their response on 6 March 2024. View source
Action
Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Require acute withdrawal prescribers to complete recognised specialist substance-misuse training to at least RCGP part-one level.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Employ a full-time substance-misuse practitioner to oversee five-day reviews, quality assurance, audit, supervision and team development.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source See 4 more actions
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AI-generated summary
Mr Lee Martin Hughes, also known as Martin Lee Hughes · 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
Lee Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider individual patient applicability when following prescribing guidelines
Wider context from the report “3. That guidelines are followed without sufficient consideration as to whether they apply to the individual patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist expertise in prescribing drug treatments for withdrawal
Wider context from the report “2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners , who should therefore be more experienced as to when, whether and how much to prescribe .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to withhold or reduce methadone when patients show signs of sedation
Wider context from the report “5. That methadone should be withheld and or reduced if the patient/inmate is showing signs of sedation .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Overreliance on subjective withdrawal symptoms rather than objective signs when assessing methadone need
Wider context from the report “1. That clinicians, wishing to believe their patients, are relying too heavily on what patients tell them (symptoms) rather than looking for evidence (physical signs) of withdrawal , As such, given the particular difficulties of prescribing to prisoners, that objective signs of withdrawal assessments (OWS) should be used to determine whether methadone should be prescribed rather than the COWS score which contains many subjective factors and may be more easily manipulated by an inmate to appear as if that inmate is experiencing withdrawal from drugs necessitating an increase in methadone.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone
Wider context from the report “4. That practitioners when prescribing consider whether time spent in custody prior to remand may have reduced an individual's tolerance to opiates , especially when methadone is to be prescribed with a synergistic agent such as a benzodiazepine .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of near-patient illicit-drug testing for assessing intoxication
Wider context from the report “6. That there should be tests available for illicit drugs from near patient testing to allow a clinician to better assess a patient showing signs of intoxication .
” 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 Deliver case-based learning for prescribers on prioritising objective withdrawal signs over reported symptoms.
Verbatim wording from the response “As a result, HMP Wandsworth healthcare has already delivered a case-based learning event for all its prescribers, focussing on the risks of over relying on reported symptoms over verifiable clinical signs.” Source location Response from Oxleas 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 Stock and mandate near-patient urine drug testing for patients presenting with sedation of unknown cause, making tests available to clinicians.
Verbatim wording from the response “6. HMP Wandsworth has investigated the commercially available near patient urine tests for drugs, including psychoactive substances (‘spice’). HMP Wandsworth now stock a test which detects a wider variety of prescribed and illicit drugs. These tests are now mandated for patients who present with sedation of unknown cause. The limitations of these tests, particularly false negatives, are well known to substance misuse practitioners. However, they are a useful aid to the management of patients whose urine test suggests continuing illicit drug use on a prison wing. These tests are currently being used and are available to all clinicians.” Source location Response from Oxleas 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 Follow national guidance on any revised opiate withdrawal scale and support implementing an approved change.
Verbatim wording from the response “1. The replacement of COWS with an Opiate Withdrawal Scale which excludes subjective reported symptoms would provide a more objective measure of opiate withdrawal and has great merit. Oxleas NHS Foundation Trust would require any deviation from current standards to be ratified at a national level and across the entire prison estate before it could be recommended as standard care. This has been raised with commissioners and we will follow up the direction from NHSE in relation to the use of a new withdrawal scale, and will fully support implementation of any revision to national guidance. In the interim I do recognise and recommend that clinicians should focus more on objective signs of withdrawal than subjective ones.” Source location Response from Oxleas 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 the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Verbatim wording from the response “3. This case has provoked a great deal of reflection on the balance of risks and benefits of methadone, especially in the first days of drug accumulation, and when prescribed alongside benzodiazepines or other sedatives. The findings and recommendations of Mr Hughes’ inquest have been shared with all prescribers. His case has already been discussed within a reflective practice forum for prescribers, focussing on the judicious interpretation of the individual patient’s history, clinical signs and investigations (such as urine drug screens), to prioritise safety with a ‘start low and go slow’ approach, even when this is unpopular with the patient.” Source location Response from Oxleas 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 Require acute withdrawal prescribers to complete recognised specialist substance-misuse training to at least RCGP part-one level.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas 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 Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas 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 Employ a full-time substance-misuse practitioner to oversee five-day reviews, quality assurance, audit, supervision and team development.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas 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 Adopting an Opiate Withdrawal Scale requires national ratification and NHS England direction before it can become standard care.
Verbatim wording from the response “1. The replacement of COWS with an Opiate Withdrawal Scale which excludes subjective reported symptoms would provide a more objective measure of opiate withdrawal and has great merit. Oxleas NHS Foundation Trust would require any deviation from current standards to be ratified at a national level and across the entire prison estate before it could be recommended as standard care. This has been raised with commissioners and we will follow up the direction from NHSE in relation to the use of a new withdrawal scale, and will fully support implementation of any revision to national guidance. In the interim I do recognise and recommend that clinicians should focus more on objective signs of withdrawal than subjective ones.” Source location Response from Oxleas NHS Foundation Trust
Open published response
21 Dec 2023 Denise Jane PORTER · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Failure to scrutinise all information contained within British Transport Police referrals View source Failure to make relevant inquiries when British Transport Police reporting is ambiguous or incomplete 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
Denise Jane PORTER · 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
Denise Jane PORTER died after jumping onto the tracks at Turnham Green Underground Station in front of an oncoming train on 19 February 2023. A prior similar incident had been referred to Oxleas NHS Trust, but the Trust relied on a partial summary and did not make further inquiries into the available police information. The report raised concern that this resulted in missed opportunities to recognise the level of risk and make an appropriate referral or care plan.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to scrutinise all information contained within British Transport Police referrals
Wider context from the report “The inquest heard the Trust did not interrogate the Safeguarding and Vulnerability Report, prepared by British Transport Police. The Trust Staff relied on the summary of the incident, both at the triage stage and subsequently during the psychiatric reviews. The Trust staff did not contact British Transport Police again to establish any information about the incident (for example the CCTV was not viewed nor a summary of the footage requested, nor were any meetings convened or discussions held between the Trust and British Transport Police).
The Trust conducted a review of the care and treatment provided to Mrs Porter. Their Report stated: "Had the referral from BTP to OACMHT included a full account of the circumstances of the incident on 25 January 2023, the OACMHT would have had a fuller understanding of the level of intent exhibited on that occasion, and subsequently risks would have been determined as high, and a more robust plan of care implemented to mitigate against these risks, that would have been immediately shared with her family". It was established at Inquest that had the full details of the incident on 25th January 2023 been understood - ie that Denise intended to take her life and this was only prevented by the slowing and halting of the train - that the psychiatrist would have referred her either to the Intensive Home Treatment Team (with consent) or for a Mental Health Act assessment (if no consent had been forthcoming).
The Trust's Report stated: "There were no identified service delivery issues that impacted on the services' ability to offer care and treatment". However, in oral evidence, the Trust's witness agreed this was inaccurate, following reflection upon the missed opportunities of investigating the events of 25th January 2023.
The Trust was unable to provide the Inquest with information to satisfy my concern that the Trust has robust systems in place to avoid the risk that staff may rely upon short summaries from British Transport Police, rather than scrutinising all the information contained within a referral and making relevant inquiries if the reporting is ambiguous or incomplete.
In this case, the Trust was clearly of the view that the detail was significant but was overly reliant upon partial information which resulted in missed opportunities for appropriate referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make relevant inquiries when British Transport Police reporting is ambiguous or incomplete
Wider context from the report “The inquest heard the Trust did not interrogate the Safeguarding and Vulnerability Report, prepared by British Transport Police. The Trust Staff relied on the summary of the incident, both at the triage stage and subsequently during the psychiatric reviews. The Trust staff did not contact British Transport Police again to establish any information about the incident (for example the CCTV was not viewed nor a summary of the footage requested, nor were any meetings convened or discussions held between the Trust and British Transport Police ).
The Trust conducted a review of the care and treatment provided to Mrs Porter. Their Report stated: "Had the referral from BTP to OACMHT included a full account of the circumstances of the incident on 25 January 2023, the OACMHT would have had a fuller understanding of the level of intent exhibited on that occasion, and subsequently risks would have been determined as high, and a more robust plan of care implemented to mitigate against these risks, that would have been immediately shared with her family". It was established at Inquest that had the full details of the incident on 25th January 2023 been understood - ie that Denise intended to take her life and this was only prevented by the slowing and halting of the train - that the psychiatrist would have referred her either to the Intensive Home Treatment Team (with consent) or for a Mental Health Act assessment (if no consent had been forthcoming).
The Trust's Report stated: "There were no identified service delivery issues that impacted on the services' ability to offer care and treatment". However, in oral evidence, the Trust's witness agreed this was inaccurate, following reflection upon the missed opportunities of investigating the events of 25th January 2023.
The Trust was unable to provide the Inquest with information to satisfy my concern that the Trust has robust systems in place to avoid the risk that staff may rely upon short summaries from British Transport Police, rather than scrutinising all the information contained within a referral and making relevant inquiries if the reporting is ambiguous or incomplete .
In this case, the Trust was clearly of the view that the detail was significant but was overly reliant upon partial information which resulted in missed opportunities for appropriate referral.
” Open source report
27 Nov 2023 Luke Mervyn WHITELAW · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Risk formulations failing to incorporate current and historic or contextual risks and mood ratings linked to interventions View source Failure to re-admit patients to hospital when indicated View source Lack of a meaningful plan to address identified safety concerns View source Failure to act on urgent psychiatric review referrals View source Failure to clearly document risk discussions and assessments View source Lack of professional curiosity in assessment and care planning View source Failure to fully explore reported deterioration after hospital discharge View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Audit risk-assessment quality and prevent unsupported low, medium or high risk stratification.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023. View source
Action
Ringfence team time for complex-case discussions and facilitate weekly formulation and risk-assessment sessions.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2023. View source
Action
Update the acute mental health patient-flow and bed-management policy to guide inpatient admission decisions.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2023. View source
Action
Train clinicians to document medication and medical-review discussions, decisions, participants, timings and outcomes.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2023. View source
Action
Train and accredit crisis-resolution and home-treatment staff in DICES risk assessment and management.
Stated completedThe respondent said that this action was complete when they made their response on 6 December 2023. View source
Action
Implement and monitor an improvement plan addressing clinical-care, risk-assessment, documentation and reflective-practice gaps.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023. View source
Action
Review the Trust electronic-record risk-assessment template to support improved risk assessment, formulation, communication and recording.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023. View source
Action
Support Greenwich Home Treatment Team staff to apply DICES learning in daily practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023. View source
Action
Continue the Heads Together skills-development programme focused on assessment, risk assessment and robust formulation.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023. View source
Action
Introduce a single crisis-assessment form capturing the person’s journey and prior assessment information in the clinical record.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023. View source See 7 more actions
×
AI-generated summary
Luke Mervyn WHITELAW · 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
Luke Mervyn Whitelaw, who was known to mental health services, died by suicide; his body was recovered from the River Thames on 17 March 2023. Before his death, his mental health deteriorated and a referral for urgent psychiatric review following his disclosure that he would accept informal hospital admission was not acted on. Concerns included insufficient consideration of historic and current risks, inadequate documentation and exploration of deterioration, and a lack of reassurance that identified learning points would be addressed.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk formulations failing to incorporate current and historic or contextual risks and mood ratings linked to interventions
Wider context from the report “(3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:
• There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment
• “Discussions and assessments of risk should be clearly documented”
• “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
• There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”
However, the Serious Incident Investigation Report does include any plan to address the concerns it identified. As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to re-admit patients to hospital when indicated
Wider context from the report “(1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a meaningful plan to address identified safety concerns
Wider context from the report “(3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:
• There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment
• “Discussions and assessments of risk should be clearly documented”
• “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
• There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”
However, the Serious Incident Investigation Report does include any plan to address the concerns it identified . As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on urgent psychiatric review referrals
Wider context from the report “(2) A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document risk discussions and assessments
Wider context from the report “(3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:
• There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment
• “Discussions and assessments of risk should be clearly documented”
• “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
• There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”
However, the Serious Incident Investigation Report does include any plan to address the concerns it identified. As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity in assessment and care planning
Wider context from the report “(3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:
• There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment
• “Discussions and assessments of risk should be clearly documented”
• “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
• There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”
However, the Serious Incident Investigation Report does include any plan to address the concerns it identified. As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully explore reported deterioration after hospital discharge
Wider context from the report “(3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:
• There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment
• “Discussions and assessments of risk should be clearly documented”
• “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”
• There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”
However, the Serious Incident Investigation Report does include any plan to address the concerns it identified. As such, there insufficient reassurance that there is plan to address the matters in a meaningful way moving forward.
” 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 Audit risk-assessment quality and prevent unsupported low, medium or high risk stratification.
Verbatim wording from the response “• The team managers, with the support of the Practice Development nurses, audit the quality of risk assessments and to ensure that practitioners are not stratifying risks as low, medium or high.” Source location Response from Oxleas 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 Ringfence team time for complex-case discussions and facilitate weekly formulation and risk-assessment sessions.
Verbatim wording from the response “• Protected time ringfenced for the team to prioritise discussion of complex cases.” Source location Response from Oxleas 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 Update the acute mental health patient-flow and bed-management policy to guide inpatient admission decisions.
Verbatim wording from the response “Oxleas Acute Mental Health Patient Flow and Bed Management policy (updated in December 2023) provides guidance on the purpose of an inpatient admission; and actions to be taken when Crisis Resolution and Home Treatment Team (CRHTT) identify that someone’s clinical needs indicate that” Source location Response from Oxleas 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 Train clinicians to document medication and medical-review discussions, decisions, participants, timings and outcomes.
Verbatim wording from the response “We have discussed with the team members of CRHTT the need to precisely document discussions about medication or medical review in future (i.e. to outline date and time of discussion, who was involved in the discussion, and the outcome that was agreed). Since this time, significant discussion and training has taken place with all clinicians in this team to document key discussions and decisions – including when the clinical needs changes to the point that inpatient care is indicated. Training and discussion has also taken place during 2023 and into 2024 with the consultant psychiatrists, managers and clinical staff about meaningful discussion and documentation of same, and consideration of written notes.” Source location Response from Oxleas 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 Train and accredit crisis-resolution and home-treatment staff in DICES risk assessment and management.
Verbatim wording from the response “The Greenwich CRHTT has received DICES training, delivered by Association of Psychological Therapies. DICE Risk Assessment and Management System helps a practitioner assess risk using a system of checklist whereby all the risks that a client in crisis may be susceptible to are asked and explored by the practitioner.” Source location Response from Oxleas 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 Implement and monitor an improvement plan addressing clinical-care, risk-assessment, documentation and reflective-practice gaps.
Verbatim wording from the response “In 2023 an improvement plan was put in pace for this clinical team to address gaps which were identified during the investigation and gaps which were identified as a result of day-to-day oversight. This plan is monitored by the service director and the clinical director for the Acute & Crisis Directorate and will continue until such time that we are satisfied that the care provided is to the standard needed, and for at least until July 2024.” Source location Response from Oxleas 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 Review the Trust electronic-record risk-assessment template to support improved risk assessment, formulation, communication and recording.
Verbatim wording from the response “• On a trust wide basis, work is underway to review the Trust Risk assessment template on the electronic patient record. This will support the embedding of the fresh approach to risk assessment, formulation, communication and recording.” Source location Response from Oxleas 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 Support Greenwich Home Treatment Team staff to apply DICES learning in daily practice.
Verbatim wording from the response “• In addition, the Practice Development Nurse and Quality Improvement lead have been supporting the Greenwich HTT to apply the learning into day-to-day practice” Source location Response from Oxleas 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 Continue the Heads Together skills-development programme focused on assessment, risk assessment and robust formulation.
Verbatim wording from the response “• The “Heads Together” CRHTT skills and development programme to improve skills competencies is ongoing with the Greenwich Home Treatment with a focus on assessments, risk assessments and robust formulations.” Source location Response from Oxleas 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 Introduce a single crisis-assessment form capturing the person’s journey and prior assessment information in the clinical record.
Verbatim wording from the response “We have also had intensive engagement with clinicians and the transformation team to co- design a single crisis assessment form that allows to capture a person journey /story in one single document on the patient recording system. This would prompt clinicians to add to assessment that was carried out previously which reduce the risks of clinicians not considering the full information on what has been happening in that person care. The form has recently gone live on the Patient clinical record as of 22 January 2024 and is on testing phase for which we are collecting feedback.” Source location Response from Oxleas NHS Foundation Trust
Open published response
17 Jan 2023 John Allen Martin HENDERSON · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Failure to provide closer monitoring for prisoners with seizure activity View source Failure to conduct start-of-day prisoner welfare checks View source Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Allen Martin HENDERSON · 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
John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide closer monitoring for prisoners with seizure activity
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity . That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John .
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct start-of-day prisoner welfare checks
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity. That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John.
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021 .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers
Wider context from the report “I asked additional questions of witnesses and asked to have sight of policies and procedures
in respect of information sharing protocols and procedures in respect of prisoners with chronic
conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did
not appear to be a clear process for prisoners to consent to disclosure of medical information
to front line officers so that they could be made aware that a particular prisoner may be prone
to sudden or unexpected medical episodes.
My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical
episode and front line prison staff may not be made aware of what was causing the issue or
how to respond thereto .
” 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 Implement Personal Management Plans to obtain consent, share relevant medical alerts and guidance, record required observations, and review at multidisciplinary prison meetings.
Verbatim wording from the response “Since this inquest, Oxleas NHS Foundation Trust has worked closely with HMPPS to introduce a Personal Management Plan (PMP) which provides a way of sharing information between healthcare staff and prison officers.” Source location Response from Oxleas Forensic and Offender Healthcare Services
Open published response
10 Nov 2022 Samuel Robert Pearson · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Failure of authorities to maintain partnership working during emergency decants View source Failure of authorities to share information during emergency decants View source Delays in screening referrals by the ADAPT service View source Failure to inform referrers when referral services cannot meet usual service expectations 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
Samuel Robert Pearson · 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
Samuel Robert Pearson had complex mental and physical needs and was moved to temporary accommodation after a van crashed into his home. The inquest narrative stated that the accident and accommodation increased his anxiety, and that he accidentally died after taking an overdose and alcohol on 6 July 2021. Concerns included inadequate multi-agency working and information sharing during the emergency move, and a referral-screening backlog that was not communicated to his GP.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of authorities to maintain partnership working during emergency decants
Wider context from the report “(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of authorities to share information during emergency decants
Wider context from the report “(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in screening referrals by the ADAPT service
Wider context from the report “(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform referrers when referral services cannot meet usual service expectations
Wider context from the report “(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues . A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations .
” 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 Complete the ADAPT Operational Policy to define waiting-time information provided to service users and referrers after referral receipt.
Verbatim wording from the response “At the inquest we confirmed that we had been reviewing our ADAPT Operational Policy, however, it had not concluded in terms of how we would inform referrers about service expectations. Our new policy is now complete, and it now clearly sets out the expectations of what information services users and the referrer will receive once the Team receive the referral in terms of waiting times. A copy of the new Operational Policy incorporating this new process is enclosed with this response.” Source location Response from Oxleas 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 Generate automated referral acknowledgements and send service users and referrers letters stating current waiting times and escalation advice for urgent referrals.
Verbatim wording from the response “An automated email will be generated and sent to the referrer:” Source location Response from Oxleas NHS Foundation Trust
Open published response
8 Nov 2022 Liridon Salikuка · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of disability awareness among prison staff View source Lack of accessible documentation of required disability adjustments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liridon Salikuка · 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
Liridon Saliuka was a remand prisoner at HMP Belmarsh who, after being moved from a medical cell to an ordinary cell without a special bed or mattress, hung himself in his cell on 2 January 2020. The report identified failures to recognise and accommodate his disability, inadequate care coordination and record keeping, and discriminatory and dismissive treatment. It also raised concerns about the lack of clear documentation of required adjustments and insufficient disability awareness among prison staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of disability awareness among prison staff
Wider context from the report “2. To the Governor of Belmarsh. There was a lack of disability awareness amongst prison staff of all levels . For example, there was an assumption that a prisoner could not be disabled because he used the gym and had good upper body strength .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible documentation of required disability adjustments
Wider context from the report “1. To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner’s disability ,
” 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 Document required disability adjustments on the Prison Nomis system, accessible to prison, healthcare and social-care providers.
Verbatim wording from the response “When a patient is identified as requiring adjustments to their disability that these will now be documented on the Prison Nomis (P-Nomis) system. Agreement was reached following senior management review by HMP Belmarsh, Royal Borough of Greenwich Social Care and Oxleas NHS Foundation Trust. All these providers have access to p-nomis.” Source location Response from Oxleas NHS Foundation Trust
Open published response
24 Oct 2022 Bradleigh Trevor Barnes · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of national guidance for healthcare staff on the use of force in prison View source Absence of a local operating policy on the use of force between prison and healthcare services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bradleigh Trevor Barnes · 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
Bradleigh Trevor Barnes was found suspended by a ligature in his cell at HMP YOI Portland on 28 December 2019. The inquest concluded that the death was suicide. Concerns included a lack of national NHS guidance for healthcare staff on the use of force in prison and the absence of a local operating policy between the prison and healthcare provider at HMP YOI Portland.
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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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for healthcare staff on the use of force in prison
Wider context from the report “i. There is a lack of national guidance to healthcare staff on the use of force in prison and I request consideration is given by NHS England to providing such national guidance.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a local operating policy on the use of force between prison and healthcare services
Wider context from the report “ii. There is no local operating policy on the use of force at HMP YOI Portland between the healthcare and the prison and I request that the Governor of HMP YOI Portland and the Chief Executive of Oxleas consider putting a local instruction policy 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 Implement a memorandum of understanding governing healthcare attendance at, and planned participation in, use-of-force interventions.
Verbatim wording from the response “We have now put in place a memorandum of understanding between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions in accordance with the HM Prison Service, Prison Service Order: Order Number 1600 – Use of Force (see attached)” Source location Response from NHS Oxleas
Open published response
30 Sep 2021 Stephen David COPE · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication View source ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses 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.
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AI-generated summary
Stephen David COPE · 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
Stephen David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about them.
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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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her .
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual .
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual.
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT , which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report
11 Dec 2020 CLAIRE LILLEY · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of a centralised, formulated risk record View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
CLAIRE LILLEY · 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
Claire Lilley was detained under the Mental Health Act and admitted to Avery Ward following a significant overdose. While on Section 17 overnight leave at home, she hung herself on 12 February and did not survive. The report identified diffuse risk information, no central risk formulation, and insufficient management cover to review risk as substantive concerns.
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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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a centralised, formulated risk record
Wider context from the report “(1) Individuals who are the subject of detainment under the Mental Health Act are risk assessed at numerous times. For those that are on Section 17 home leave, they are additionally assessed prior to leaving the ward on each occasion. In addition, risks are also reviewed on the regular multi-disciplinary ward rounds.
(2) However, such assessments are not centralised in any one place – there is no central formulation . Reviews by any clinician would have to cover 3 or 4 different entries by way of example: the risk assessment page, the MDT notes, the psychology entries (although they, per se, do not enter risks assessments).
(3) The Court’s expert confirmed that such a centralisation/ formulation (supported by the Route Cause Analysis report), would assist in reviewing an individual’s risk and allowing ward staff to see the wider input in one place.
(4) Training has been implemented by the Trust to assist staff in formulating risk, a process that was in place at the time of Claire’s death. However, there is no central repository/formulation of the outcomes of those assessments . Different teams continue to use different tools; there is no stand-alone document .
(5) Consideration should therefore be given to the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of their own speciality.
” 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 Introduce the Risk Assessment document as the central risk record and add a mandatory formulation summary that flows to the MDT template and inpatient care plan.
Verbatim wording from the response “The Risk Assessment document will now be the centralised document for all professionals to document all risks immediately. To support, a new mandatory section will be added to the Risk Assessment document in RiO. This section will be a formulation summary. This summary will then automatically pull through to show on the MDT template and the inpatient care plan.” Source location 2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require each MDT meeting to decide risk, allocate responsibility for updating records, and update the Risk Assessment and associated care-plan management after identified risks.
Verbatim wording from the response “4. A decision will be made about the risk at every MDT meeting. The MDT meeting will record as an action, who present at the MDT is going to update the risk assessment for a service user and then ensure that it is done. The allocated clinician will update the RiO Risk Assessment and associate management plan in the care plan for every risk identified after the MDT so it captures what was discussed and agreed.” Source location 2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require all clinicians to update the Risk Assessment whenever risk changes between MDT meetings.
Verbatim wording from the response “6. If anything changes in the period between MDTs, as stated, all clinicians will be expected to exercise their individual responsibility to personally update the Risk Assessment.” Source location 2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
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 Reinforce that every professional must record identified risks immediately in the Risk Assessment document.
Verbatim wording from the response “1. Reinforce that all professionals are responsible for taking ownership for updating the Risk Assessment document. This will address an over reliance by multi-professional teams (nurses, psychologists, occupational therapists etc) on Consultants to update the Risk Assessment document. This means that in addition to escalating risks to the Consultant that all professionals must document risks at the time they are identified. It means that all professionals will be constantly thinking about risks and updating the Risk Assessment document when things happen. This will give a much better and clearer picture of risk events rather than that which might be achieved a formulation alone.” Source location 2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
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 Remove the Responsible Clinician’s policy responsibility and assign post-MDT risk-record updates to a professional allocated during the meeting.
Verbatim wording from the response “5. To facilitate this we will remove from the current Risk Management Policy that it is the Responsible Clinician responsibility to ensure that a clinical risk assessment and clinical risk management plan is made before the decision is taken to discharge a person or grant leave. Currently the expectation is that the primary nurse does this but it is not working effectively when the primary nurse is not in the ward round. By making it the responsibility of a professional allocated at the time of the MDT meeting, the expectation that this happens immediately after the MDT meeting will ensure that the Risk Assessment document and associate management plan in the Care Plan is updated contemporaneously.” Source location 2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
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 MDT template must remain separate from the Risk Assessment document because weekly meetings cannot realistically update and summarise risk.
Verbatim wording from the response “2. Reinforce the use of the Multidisciplinary Team (MDT) template where all involved professionals are required to input their feedback ahead of an MDT meeting to include their actions about documented risks that they have identified and added to the Risk Assessment document. However this needs to remain separate to the Risk Assessment document as it is not realistic for the weekly MDT meeting to update, summarise and state what might improve or worsen the risk. Currently the MDT template is not being used as effectively as it could be in a meaningful way, evidenced by internal transfers and this is being addressed with teams to reduce the variation.” Source location 2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
Open published response
Concerns raised 2 Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources View source Failure to provide patients with information about Lamotrigine side effects View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Viktor John Anthony Scott-Brown · 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
Viktor John Anthony Scott-Brown, aged 23, was found hanging at his home overnight on 14/15 December 2018 and pronounced dead at the scene; the inquest concluded that his death was suicide. He had been prescribed Lamotrigine without being warned about its potential association with thoughts of self-harm or suicide, and concerns were raised that reputable prescribing resources were inconsistent or silent about this potential side effect.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with information about Lamotrigine side effects
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” Open source report
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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 No longer involved in the Maudsley Prescribing Guidelines and therefore cannot influence their future content.
Verbatim wording from the response “Oxleas NHS Foundation Trust no longer has any involvement in the authorship or editing of the Maudsley Prescribing Guidelines. Our last involvement was in April 2015, when the 12th edition was published.” Source location Response from Oxleas NHS Foundation Trust
Open published response
26 Jun 2020 Gary Etherington · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Lack of psychiatric follow-up or support after transfer of care to GP View source Inadequate discharge plan communicated to GP View source Failure to take and consider relevant patient history before discharge View source Failure to contact relevant corroborative sources during Mental Health Act assessment View source Failure to address referring GP concerns about patient management View source Failure to properly assess suicidal symptoms and risks before discharge View source Inadequate investigation of symptoms before discounting psychosis View source Failure of Root Cause Analysis to recognise and investigate care problems View source Underestimation of suicidality View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Establish a central Serious Incidents Team to oversee investigations, monitor incidents, ensure follow-up and share learning across the Trust.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Require primary care teams to send comprehensive letters to general practitioners covering referral issues, assessment outcomes and treatment advice.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Discuss the case learning at the Section 12 and Approved Clinician refresher course for doctors.
Stated plannedThe respondent said that this action was planned when they made their response on 14 September 2020. View source
Action
Develop the Support Network Engagement Tool to help clinicians identify and engage families, carers and other support networks.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Update the Incident Management Policy and Procedures to require investigating panels to consider care, family involvement, safety, equality and other incident issues.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Audit care plans monthly for evidence that patients’ support networks, especially families and carers, are involved.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 September 2020. View source
Action
Commission and complete a review of the Trust’s process for managing and investigating serious incidents.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Share the PFD report and response with all doctors, particularly psychiatry trainees.
Stated plannedThe respondent said that this action was planned when they made their response on 14 September 2020. View source See 5 more actions
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AI-generated summary
Gary Etherington · 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
Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric follow-up or support after transfer of care to GP
Wider context from the report “2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate discharge plan communicated to GP
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take and consider relevant patient history before discharge
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact relevant corroborative sources during Mental Health Act assessment
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address referring GP concerns about patient management
Wider context from the report “2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management , and to whom his care passed without any psychiatric follow up or support.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly assess suicidal symptoms and risks before discharge
Wider context from the report “The coroner found that there were two failures in medical care, namely
1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide , delusions of people being present, their cause and relation to drug misuse, or the risks to ████████ , about which there was an inadequate plan communicated to the GP.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate investigation of symptoms before discounting psychosis
Wider context from the report “2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation , underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Root Cause Analysis to recognise and investigate care problems
Wider context from the report “3. Neither failure was recognised or investigated by the Root Cause Analysis which was described as Level 2 Comprehensive and concluded that there were no problems in health care. The court regarded the RCA investigation as unreliable . That causes some concern as to whether the Trust is able to identify care problems in future .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Underestimation of suicidality
Wider context from the report “2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a central Serious Incidents Team to oversee investigations, monitor incidents, ensure follow-up and share learning across the Trust.
Verbatim wording from the response “In July 2018 the Trust commissioned KPMG to undertake a review of the whole process of managing and investigating Serious Incidents and the final report published in October 2018. One of the recommendations from the review was that a central Serious Incidents Team should be created to deal specifically with oversight of the investigation and monitoring of all Serious Incidents. Prior to this, Serious Incidents were investigated within the Directorates as was the death of Mr Etherington which was investigated over a 3 month period (December 2018 to February 2019).” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 primary care teams to send comprehensive letters to general practitioners covering referral issues, assessment outcomes and treatment advice.
Verbatim wording from the response “Turning to your second concern that Mr Etherington was discharged without adequate consideration of his symptoms and communication to his general practitioner, I have ensured that all our primary care teams (PCP), who are the gateway to our secondary mental health services, write comprehensive letters to general practitioners addressing the specific issues raised by the general practitioner including outlining the outcome of assessments and treatment advice.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 the case learning at the Section 12 and Approved Clinician refresher course for doctors.
Verbatim wording from the response “The Root Cause Analysis investigation concluded that the strained relationship between Mr and ████████ and the restraining order against Mr Etherington contributed to the failure to engage with ████████. To ensure learning from this incident, I will share the PFD report and this response with all doctors, especially trainees in psychiatry, and have asked that this is a topic of discussion at our Oxleas Section 12 and Approved Clinician refresher course for doctors.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the Support Network Engagement Tool to help clinicians identify and engage families, carers and other support networks.
Verbatim wording from the response “The involvement of families and carers is a Trust quality priority and the Trust has developed a Support Network Engagement Tool (SNET) to help clinicians identify key support networks and engage them in assessment and treatment. In addition, care plans are audited every month to check for evidence of involvement of each patient’s support network especially families and carers and whilst the results of these audits show improvement over the last few years but we recognise there is more to be done.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 Update the Incident Management Policy and Procedures to require investigating panels to consider care, family involvement, safety, equality and other incident issues.
Verbatim wording from the response “In addition, the Incident Management Policy and Procedures was updated in April 2019 (subsequently updated April 2020) to reflect the changes within the Serious Incident Team and stipulates that the Terms of Reference for the investigating panel must include:” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 Audit care plans monthly for evidence that patients’ support networks, especially families and carers, are involved.
Verbatim wording from the response “The involvement of families and carers is a Trust quality priority and the Trust has developed a Support Network Engagement Tool (SNET) to help clinicians identify key support networks and engage them in assessment and treatment. In addition, care plans are audited every month to check for evidence of involvement of each patient’s support network especially families and carers and whilst the results of these audits show improvement over the last few years but we recognise there is more to be done.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 and complete a review of the Trust’s process for managing and investigating serious incidents.
Verbatim wording from the response “In July 2018 the Trust commissioned KPMG to undertake a review of the whole process of managing and investigating Serious Incidents and the final report published in October 2018. One of the recommendations from the review was that a central Serious Incidents Team should be created to deal specifically with oversight of the investigation and monitoring of all Serious Incidents. Prior to this, Serious Incidents were investigated within the Directorates as was the death of Mr Etherington which was investigated over a 3 month period (December 2018 to February 2019).” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 Share the PFD report and response with all doctors, particularly psychiatry trainees.
Verbatim wording from the response “The Root Cause Analysis investigation concluded that the strained relationship between Mr and ████████ and the restraining order against Mr Etherington contributed to the failure to engage with ████████. To ensure learning from this incident, I will share the PFD report and this response with all doctors, especially trainees in psychiatry, and have asked that this is a topic of discussion at our Oxleas Section 12 and Approved Clinician refresher course for doctors.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 No further investigation is required because the Trust’s revised Root Cause Analysis process is considered thorough and comprehensive.
Verbatim wording from the response “Since the implementation of these changes to the management of Serious Incidents in April 2019, the Trust is confident that investigations are thorough, reliable and identify problems in care, with appropriate action documented to address these.” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
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 Mental Health Act does not require assessing doctors to obtain collateral information or consult others during an assessment.
Verbatim wording from the response “There is no requirement under the Mental Health Act for an assessing doctor to obtain any collateral information as part of their assessment. Section 12 of the Act requires that a doctor making a recommendation may only do so if they have personally examined the patient. There is no legal duty placed on doctors to consult each other, or anyone else. The European Courts have held that the medical assessment must be based on the actual state of mental health of the person concerned and not solely on past events (Varbanov v Bulgaria [2000] MHRR 263 para 47).” Source location 2020-0134-Response-from-Oxleas-NHS-Trust_Redacted.pdf
Open published response
21 Feb 2020 Billy James Jenkins · Prevention of Future Deaths report South London
View report summary
Concerns raised 8 Over-reliance on alcohol and drug use in assessing suicidal ideation View source Failure to complete assessment sufficient to identify mental health diagnosis requiring treatment View source Unavailability of a proforma of assessment questions View source Failure to identify training or support requirements for the Community Mental Health Nurse View source Failure to establish lessons learned by teams involved in care and treatment View source Failure to obtain sufficient assessment information before multidisciplinary mental health review and decision-making View source Failure to develop robust plans addressing protective factors and harm minimisation View source Failure to document clinical formulation or impression View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Billy James Jenkins · 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
Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on alcohol and drug use in assessing suicidal ideation
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation . There appeared to be no proforma of questions to ask.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete assessment sufficient to identify mental health diagnosis requiring treatment
Wider context from the report “(3) As a direct consequence of the limited information gathering Billy Jenkins was not properly assessed and it was not known whether he had a mental health diagnosis which required treatment .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a proforma of assessment questions
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify training or support requirements for the Community Mental Health Nurse
Wider context from the report “(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish lessons learned by teams involved in care and treatment
Wider context from the report “(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain sufficient assessment information before multidisciplinary mental health review and decision-making
Wider context from the report “(1) The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr Jenkins’ mental health . Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to develop robust plans addressing protective factors and harm minimisation
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical formulation or impression
Wider context from the report “(2) The Community Mental Health Nurse did not document her formulation or impression . The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask.
” 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 a Trust-wide rolling programme delivering STORM and DICES training on suicide prevention, risk assessment, safety planning and risk management.
Verbatim wording from the response “In order to further support staff we have instigated a Trust wide rolling programme of training for mental health community teams. This consists of STORM, a two day suicide prevention programme which offers skills based training in risk assessment and safety planning. Also we have rolled out DICES an evidence based approach to assess and manage risks. The checklist provided during this training support the formulation of risk in the risk assessment utilised by the Team. The training supports staff to notice and assess any risks present, manage the risk” Source location 2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
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 Conduct reflective-practice sessions focused on assessment, risk documentation, record keeping and formulation, with impact monitoring.
Verbatim wording from the response “As a result of the incident the community mental team core induction tool was sent to all CMHT managers to go through with all the new starters and other established colleagues to reinforce the expectations of their roles and the assessment process. This was shared with all staff in supervision and an email has also been sent to all members of staff. Reflective practice sessions have also been conducted focusing on documentation and record keeping, particularly assessment (needs and risk) and formulation. The impact of this is being monitored in Team meetings and in reflective practice meetings. This will be reviewed again after the current unusual working practices in relation to Covid 19.” Source location 2020-0068-Response-from-Oxleas-NHS-Foundation-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 Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.
Verbatim wording from the response “Since the death of Mr Jenkins the RCA report has been shared with the team and across the Trust so that similar Teams can reflect on the lessons learnt. The actions arising from the investigation have also been implemented including areas addressed above. Additional learning reflects the need to ensure that all service users who are receiving care and treatment from Oxleas mental health services and also use drugs and or alcohol have equal access to all strands of treatment available to those who are not using substances. Only if there is clear evidence that the use of substances will impact on the ability to clinically benefit from any treatment would a decision be made to withhold treatment and in these instances this would be reviewed regularly with the service user and the team.” Source location 2020-0068-Response-from-Oxleas-NHS-Foundation-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 community mental-health assessment oversight, including further face-to-face assessment where diagnoses differ and monthly quality audits.
Verbatim wording from the response “Following this incident we have taken further measures to ensure the assessment of patients within the community mental health team are robustly managed in order to ensure that the MDT has sufficient information to review an assessment and to ensure that where there is any disparity in diagnosis that a further face to face assessment is conducted. The operational team manager is monitoring this practice through discussions in Team meetings, supervisions and MDT case discussions.” Source location 2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
Open published response
8 May 2019 Bernard Pius O’Flynn · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of practising expert input into formulation of medical emergency policies View source Potential medical emergencies outside Code Red and Code Blue requiring hospital transfer within less than an hour 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
Bernard Pius O’Flynn · 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
Bernard Pius O’Flynn was imprisoned at HMP Thameside and developed back and abdominal pain before being diagnosed with an acute abdomen. His transfer to hospital was delayed for three days; he was later diagnosed with metastatic adenocarcinoma and died in hospital on 26 August 2018. The report identified concerns about urgent hospital transfers from prison, including the absence of expert emergency-medicine input into policies for emergencies outside Code Red and Code Blue situations.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practising expert input into formulation of medical emergency policies
Wider context from the report “The failures identified in the clinical review and PPO reports were, in my view, deeply troubling. That said I am encouraged by the cooperation and efforts made by Oxleas and SERCO to formulate a policy to deal with medical emergencies falling outside the Code Red and Code Blue scenarios.
However I remain concerned that a practising expert in Emergency Medicine has not yet had input into the formulation of the policies promulgated by the joint meeting between SERCO and Oxleas .
In particular my concern is that there may be medical emergencies which do not fall within Code Red or Code Blue but may, nonetheless, require immediate transfer to hospital within less than an hour. It is possible that an expert in emergency medicine would be able to easily identify whether or not there are residual cases within this category.
I am therefore of the view that I am under a duty to report this residual concern to Oxleas NHS Foundation Trust in order to take appropriate action, if so advised by an expert Consultant in Emergency Medicine, to reduce the risk of fatalities in future.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Potential medical emergencies outside Code Red and Code Blue requiring hospital transfer within less than an hour
Wider context from the report “The failures identified in the clinical review and PPO reports were, in my view, deeply troubling. That said I am encouraged by the cooperation and efforts made by Oxleas and SERCO to formulate a policy to deal with medical emergencies falling outside the Code Red and Code Blue scenarios.
However I remain concerned that a practising expert in Emergency Medicine has not yet had input into the formulation of the policies promulgated by the joint meeting between SERCO and Oxleas.
In particular my concern is that there may be medical emergencies which do not fall within Code Red or Code Blue but may, nonetheless, require immediate transfer to hospital within less than an hour . It is possible that an expert in emergency medicine would be able to easily identify whether or not there are residual cases within this category.
I am therefore of the view that I am under a duty to report this residual concern to Oxleas NHS Foundation Trust in order to take appropriate action, if so advised by an expert Consultant in Emergency Medicine, to reduce the risk of fatalities in future.
” Open source report
15 Apr 2019 Jennifer Lewis · Prevention of Future Deaths report North West Kent
View report summary
Concerns raised 3 Failure to provide appropriate care at the Centre View source Failure to provide suitable or adequate care for care needs View source Failure to arrange consultation between mental and physical health doctors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Maintain a practice-nurse and GP register for patients with long-term conditions, recording interventions, appointments, reviews, referrals and discharge follow-up.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2019. View source
Action
Discuss patients with declining physical health monthly at a complex care forum attended by the Mental Capacity lead and Independent Mental Health Advocate.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2019. View source
Action
Keep patients with long-term nutritional or dietary needs under dietetic care, with named-dietician reviews, follow-up assessments and meal-plan approval.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019. View source
Action
Record all patients’ weight and height using the MUST tool and audit completed assessments regularly across wards, including the Bracton Centre.
Stated completedThe respondent said that this action was complete when they made their response on 14 June 2019. View source
Action
Invite relevant healthcare professionals, including GPs and dieticians where necessary, to six-monthly CPA meetings for complex-case patients.
Stated plannedThe respondent said that this action was planned when they made their response on 14 June 2019. View source See 2 more actions
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AI-generated summary
Jennifer Lewis · 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
Jennifer Lewis was admitted to hospital from the Bracton Centre on 21 July 2017 with poor intake, diarrhoea, confusion, dehydration, hypotension and malnutrition, and subsequently deteriorated. The inquest concluded that she died at Darent Valley Hospital on 31 July 2017 as a result of malnutrition due to inadequate provision and intake of sufficient nourishment and nutrition, furthered by an inability to provide the necessary medical intervention at the Bracton Centre. The principal concerns were failures to arrange consultation between mental health and physical health doctors, provide suitable or adequate care for her needs, and provide appropriate care at the Centre.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate care at the Centre
Wider context from the report “(3) The failure to provide appropriate care at the Centre .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable or adequate care for care needs
Wider context from the report “(2) The failure to provide suitable or adequate care for her 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange consultation between mental and physical health doctors
Wider context from the report “(1) The failure to arrange consultation between the mental health doctors and the doctors responsible for her physical health
” 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 Maintain a practice-nurse and GP register for patients with long-term conditions, recording interventions, appointments, reviews, referrals and discharge follow-up.
Verbatim wording from the response “• All patients with a Long Term Condition (LTC), such as Ms Lewis, are now held in a LTC register managed by the practice nurse in conjunction with the GP. This is in place and all physical health interventions and scheduled appointments are recorded within this register along with proposed future review dates. Patients with complex physical health conditions are reviewed periodically by the practice nurse and the GP to ensure appropriate referrals to specialist services and arrange follow up upon discharge back to the Bracton Centre.” Source location 2019-0003-Response-by-Oxleas-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 Discuss patients with declining physical health monthly at a complex care forum attended by the Mental Capacity lead and Independent Mental Health Advocate.
Verbatim wording from the response “• All patients with declining physical health are discussed monthly at the complex care forum. The forum is chaired by the Mental Capacity lead for the directorate and attended by the Independent Mental Health Advocate (IMHA) to ensure patients’ views are fully represented. This change was implemented at the beginning of this year.” Source location 2019-0003-Response-by-Oxleas-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 Keep patients with long-term nutritional or dietary needs under dietetic care, with named-dietician reviews, follow-up assessments and meal-plan approval.
Verbatim wording from the response “• All patients identified as having long term nutritional and dietary needs will remain open to the dietician whilst at the Bracton Centre. The named dietician will be responsible for appropriate reviews, follow up assessments and approval of meal plans.” Source location 2019-0003-Response-by-Oxleas-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 all patients’ weight and height using the MUST tool and audit completed assessments regularly across wards, including the Bracton Centre.
Verbatim wording from the response “• All patients’ weight and height are now entered to the Malnutrition Universal Screening Tool (MUST) which has been available on our clinical records system, RiO, since June 2017. The change brings our practice into line with national guidance for nutrition and hydration, as set out by the National Institute of Health & Care Excellence (CG32, QS24), the British Association of Parenteral and Enteral Nutrition and the Care Quality Commission. Our dietetic service undertake regular audits of completed MUST assessments to ensure the change in practice is embedded within all wards, including those at the Bracton Centre.” Source location 2019-0003-Response-by-Oxleas-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 Invite relevant healthcare professionals, including GPs and dieticians where necessary, to six-monthly CPA meetings for complex-case patients.
Verbatim wording from the response “• All relevant healthcare professionals, including the GP and dieticians where necessary, will be invited to six monthly Care Programme Approach (CPA) meetings for patients on the complex case caseload.” Source location 2019-0003-Response-by-Oxleas-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 Bracton Centre’s service model limits its ability to provide specialist physical health services on site.
Verbatim wording from the response “The nature of the service at the Bracton Centre limits to some extent our ability to provide specialist physical health services on site, however I hope the information provided reassures you that the findings of your investigation and areas identified for the prevention of future deaths have prompted appropriate action on our part.” Source location 2019-0003-Response-by-Oxleas-NHS-Trust
Open published response
29 Oct 2018 Mr Thomas Patrick McAuley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to provide prison doctors access to uploaded prison case history notes View source Failure to ensure universal availability of DPMFs to health care staff View source Failure to ensure sufficient time for reception nurses to review DPMFs View source Failure of police doctors to communicate directly with prison health care staff or transfer medical information between doctors View source Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records View source Failure to provide DPMFs to health care staff View source Unavailability of DPMFs in prison wings View source See 4 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
Mr Thomas Patrick McAuley · 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
Mr Thomas Patrick McAuley was found dead in his prison cell on 23 August 2017. The medical cause of death was bronchopneumonia, with chronic bronchitis and alcohol and drug dependence also recorded. The inquest identified concerns about clinical information from police custody not being available to all prison clinical staff and a lack of clinical observations during the first five days of methadone treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison doctors access to uploaded prison case history notes
Wider context from the report “3. An Oxleas manager said that the case history notes from the prison were uploaded onto PNomis, but a prison doctor did not think he had access to this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure universal availability of DPMFs to health care staff
Wider context from the report “4. A representative of Oxleas HC reported that a new process required a nurse to tick a box when the DPMF was uploaded onto the medical records, but there was no evidence that the DPMF is universally available to health care staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficient time for reception nurses to review DPMFs
Wider context from the report “1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these . The DPMF was not available in the wings.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police doctors to communicate directly with prison health care staff or transfer medical information between doctors
Wider context from the report “5. There was no evidence that police doctors communicated directly with health care staff in prison , or arranged for transfer of medical information between doctors . (The police doctors were not called).
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records
Wider context from the report “6. In conclusion, there is no assurance that doctors attending in custody, the prison service and those providing health care in prisons have established a fail-safe mechanism of ensuring that medical assessments on vulnerable individuals and records from custody are seen and considered by medical staff in prison .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide DPMFs to health care staff
Wider context from the report “2. A manager of the drug addiction services in the prison said that health care staff were not always given the DPMF .
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of DPMFs in prison wings
Wider context from the report “1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these. The DPMF was not available in the wings .
” Open source report
1 Apr 2018 Julia Jane MacPherson · Prevention of Future Deaths report South London
View report summary
Concerns raised 6 Failure to follow NICE guidelines for prescribing off-licence medicines View source Failure to provide timely clinical review following reported deterioration View source Failure of hospital staff to regularly read clinical and nursing entries in patient medical records View source Failure to formally review mental capacity to consent to treatment View source Absence of a statutory process for recording informal patients' consent to medication View source Incomplete or missing records of consent discussions for off-licence mental health medication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Continue auditing MDT template use, capacity assessments, and responses to family concerns.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 January 2019. View source
Action
Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.
Stated completedThe respondent said that this action was complete when they made their response on 19 January 2019. View source
Action
Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.
Stated plannedThe respondent said that this action was planned when they made their response on 19 January 2019. View source
Action
Send all doctors relevant guidance on prescribing off-license medicines and require them to follow it in practice.
Stated plannedThe respondent said that this action was planned when they made their response on 19 January 2019. View source
Action
Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
Stated plannedThe respondent said that this action was planned when they made their response on 19 January 2019. View source
Action
Write to all consultants reiterating expectations to read clinical and nursing notes written by trainees and other staff.
Stated plannedThe respondent said that this action was planned when they made their response on 19 January 2019. View source
Action
Require doctors to include off-license prescribing practice in appraisals and reflect on its effect on their practice.
Stated plannedThe respondent said that this action was planned when they made their response on 19 January 2019. View source
Action
Hold an educational meeting before the end of summer to reinforce off-license prescribing guidance and its application.
Stated plannedThe respondent said that this action was planned when they made their response on 19 January 2019. View source See 5 more actions
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AI-generated summary
Julia Jane MacPherson · 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
Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines for prescribing off-licence medicines
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely clinical review following reported deterioration
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May .
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital staff to regularly read clinical and nursing entries in patient medical records
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records .
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review mental capacity to consent to treatment
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a statutory process for recording informal patients' consent to medication
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete or missing records of consent discussions for off-licence mental health medication
Wider context from the report “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however:
(a) This review did not take place and her Responsible Clinician did not see this note until the inquest.
(b) Julia was not reviewed on 16th May.
(c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May.
(2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records.
(3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised.
(4) NICE guidelines for the prescription of off licenced medicines was not followed.
(5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients.
” 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 Continue auditing MDT template use, capacity assessments, and responses to family concerns.
Verbatim wording from the response “A recent audit of the use of the MDT template and capacity assessments have shown that it is being used and that views and concerns of families are being addressed. These audits will be carried out on a regular basis to give assurance to the trust.” Source location 2018-0298-Oxleas-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 Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.
Verbatim wording from the response “The Trust has developed a Multidisciplinary Team (MDT) meeting template following a quality improvement project to enable every member of the MDT to contribute to the review. There is a section for families, carers and significant people in a service user’s life in which any concerns raised are documented to ensure these are discussed in the meeting and agreed actions to address these outlined.” Source location 2018-0298-Oxleas-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 Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.
Verbatim wording from the response “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.” Source location 2018-0298-Oxleas-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 Send all doctors relevant guidance on prescribing off-license medicines and require them to follow it in practice.
Verbatim wording from the response “Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.” Source location 2018-0298-Oxleas-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 Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
Verbatim wording from the response “The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.” Source location 2018-0298-Oxleas-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 Write to all consultants reiterating expectations to read clinical and nursing notes written by trainees and other staff.
Verbatim wording from the response “In addition, our Medical Director, Dr Okocha will write to all consultants in the Trust reiterating the expectations that they check and read notes which are written by their trainees and other staff.” Source location 2018-0298-Oxleas-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 Require doctors to include off-license prescribing practice in appraisals and reflect on its effect on their practice.
Verbatim wording from the response “Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.” Source location 2018-0298-Oxleas-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 Hold an educational meeting before the end of summer to reinforce off-license prescribing guidance and its application.
Verbatim wording from the response “Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.” Source location 2018-0298-Oxleas-NHS-Foundation-Trust
Open published response
6 Mar 2018 Rastislav Petrisko · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Delays in notifying police when patients fail to return from leave View source Lack of recorded drug-screening results on return from leave View source Failure to use a consistent risk-assessment method for vulnerable patients granted leave 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
Rastislav Petrisko · 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
Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.
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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in notifying police when patients fail to return from leave
Wider context from the report “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit).
Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time . This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long . The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk .
The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded drug-screening results on return from leave
Wider context from the report “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit).
Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission . A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk.
The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other.
” 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 Oxleas NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a consistent risk-assessment method for vulnerable patients granted leave
Wider context from the report “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit).
Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance . In retrospect the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk.
The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation , one with greater potential of saving his life than the other.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations