Pavilions

Private and voluntary organisations · Multi-service care provider

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First report 2 Aug 2017•Latest report 2 Aug 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Pavilions linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Brighton and Hove

    AI-generated summary

    Thomas Christall · 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 Christall’s inquest concluded that he took his own life. Concerns included the lack of a local inpatient detoxification facility, long waiting times, and insufficiently collaborative treatment for people with dual diagnosis, with delays and refusals increasing distress and despair.

    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 Pavilions; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of local in-patient detoxification facility availability

    Wider context from the report

    “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK? ”
    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 Pavilions; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide collaborative, integrated dual diagnosis treatment and assessment

    Wider context from the report

    “(2) A much more collaborative approach to dual diagnosis patient's treatment is needed. The dual diagnosis is at the heart of this problem. It is not appropriate to try to separate each component and only agree to treat/assess one component when the other is dealt with. The dual diagnosis is the person. When in crisis they are doubly at risk. That period of risk should be reduced as quickly as possible. The delays and refusals serve to exacerbate the patient's distress and increase their despair. As Thomas Wall said in a text message to his supportive ex-wife ‘I want to get better but I can’t do that on my own whereas I can take my life on my own’ ”
    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 Pavilions; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in access to in-patient detoxification

    Wider context from the report

    “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK? ”
    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

Data last updated 7 September 2026