20 Jan 2026 Linda Fury · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure of the investigation to substantiate the finding that there was no reason to doubt capacity View source Ward-round processes failing to facilitate private family disclosure of risk concerns to the multi-disciplinary team View source Failure of the investigation to critically analyse decisions to rescind section and discharge without trialling s17 leave View source Failure of the investigation to examine the consequences of no local bed availability for continuity of care View source See 1 more concern
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AI-generated summary
Linda Fury · 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
Linda Fury, who had a long history of severe and enduring mental illness, died at home on 3 May 2025 after being discharged from hospital following the rescinding of her detention. The report identifies concerns about the discharge decision, including insufficient consideration of family information and the failure to trial home leave or provide step-down care. It also raises concerns about the insufficient rigour of the Trust’s investigation and ward-round processes not routinely allowing families to share risk concerns privately.
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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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the investigation to substantiate the finding that there was no reason to doubt capacity
Wider context from the report “1. In view of the importance of robust NHS investigations in preventing future deaths undertaken from the perspective of seeking to derive as much learning as possible, I am concerned the Trust’s investigation in this case was insufficiently rigorous or probing given:
a. It has not focussed in any detail on the consequences arising for Linda (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally;
b. The investigation does not undertake any meaningful critical analysis of the decision-making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled; and
c. In respect of findings made in relation to the care provided on the day before Linda’s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) “[t]here was no reason to doubt Linda’s capacity at this stage” in circumstances where the Trust was on notice she not attending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ward-round processes failing to facilitate private family disclosure of risk concerns to the multi-disciplinary team
Wider context from the report “2. I am concerned that the current processes for ward rounds do not routinely facilitate an opportunity for family members to disclose any concerns relevant to risk privately to the multi-disciplinary team .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the investigation to critically analyse decisions to rescind section and discharge without trialling s17 leave
Wider context from the report “1. In view of the importance of robust NHS investigations in preventing future deaths undertaken from the perspective of seeking to derive as much learning as possible, I am concerned the Trust’s investigation in this case was insufficiently rigorous or probing given:
a. It has not focussed in any detail on the consequences arising for Linda (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally;
b. The investigation does not undertake any meaningful critical analysis of the decision-making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled ; and
c. In respect of findings made in relation to the care provided on the day before Linda’s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) “[t]here was no reason to doubt Linda’s capacity at this stage” in circumstances where the Trust was on notice she not attending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the investigation to examine the consequences of no local bed availability for continuity of care
Wider context from the report “1. In view of the importance of robust NHS investigations in preventing future deaths undertaken from the perspective of seeking to derive as much learning as possible, I am concerned the Trust’s investigation in this case was insufficiently rigorous or probing given:
a. It has not focussed in any detail on the consequences arising for Linda (in terms of continuity of care and more broadly) as a result of the fact that no bed was available for her locally ;
b. The investigation does not undertake any meaningful critical analysis of the decision-making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled; and
c. In respect of findings made in relation to the care provided on the day before Linda’s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) “[t]here was no reason to doubt Linda’s capacity at this stage” in circumstances where the Trust was on notice she not attending to self-care, barely eating or drinking and refusing to speak with or see her Care Co-ordinator.
” 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 Pilot a carer questionnaire to inform improvements to the MDT ward-round process.
Verbatim wording from the response “We have initiated trust-wide improvement work to ensure Multi-Disciplinary Team (MDT) documentation reliably captures patient and carer views. The identified aims of this are to:” Source location Response from Pennine Care 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 Subject investigation reports to critical scrutiny through Network Quality and Safety panels, including clinical and lived-experience perspectives.
Verbatim wording from the response “The Trust is committed to ensuring that our investigation reports are subject to appropriate levels of critical scrutiny and this occurs at the Network Quality & Safety panels. During this process a range of professional and non-professional individuals have the opportunity to comment on the draft report. At the Mental Health Network’s Quality & Safety panel, lived experience expertise is provided by our carers representative. The panel also has a medical representative who is a consultant psychiatrist; all members of the panel provide a critical challenge to the quality of” Source location Response from Pennine Care 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 Update confidentiality policy, staff and carer guidance, and carer-awareness training through the Triangle of Care working group.
Verbatim wording from the response “As part of the trust-wide Triangle of Care work, Standard 3: Confidentiality is being actively worked on. The Triangle of Care is a nationally recognised framework developed by the Carers Trust to strengthen collaboration between service users, carers, and mental health professionals. It is built on six key standards that ensure carers are identified, included, informed, and supported throughout the care” Source location Response from Pennine Care 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 Roll out the standardised pre-ward-round patient and carer form from pilot sites to all inpatient wards.
Verbatim wording from the response “A standardised Pre-Ward-Round Form for Patients and Carers has been developed with the support of the Culture of Care programme, who provide quality improvement (QI) coaches and lived experience support. These have been implemented in pilot sites and is planned to be rolled out to all inpatient wards. The form enables both patients and carers to feel heard when they are not able to attend ward round or feel unable to speak in a ward round due to feeling uncomfortable or worrying about damaging relationships with their loved ones.
The form is able to explore:” Source location Response from Pennine Care 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 Update and distribute information leaflets explaining confidential routes for carers to share concerns.
Verbatim wording from the response “In addition to this, we are strengthening the expected standards through which carers can share risk-related information outside the main ward-round or visiting environment, this includes an ability to contact the nurse-in-charge or delegated clinician privately, dedicated email/telephone routes for sharing concerns, the option to request a short one-to-one discussion with the MDT outside of the formal ward round. All information is documented in the PARIS carer space, ensuring visibility across the MDT.” Source location Response from Pennine Care 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 Strengthen confidential routes for carers to share risk information outside ward rounds, with documentation in the PARIS carer space.
Verbatim wording from the response “In addition to this, we are strengthening the expected standards through which carers can share risk-related information outside the main ward-round or visiting environment, this includes an ability to contact the nurse-in-charge or delegated clinician privately, dedicated email/telephone routes for sharing concerns, the option to request a short one-to-one discussion with the MDT outside of the formal ward round. All information is documented in the PARIS carer space, ensuring visibility across the MDT.” Source location Response from Pennine Care NHS Foundation Trust
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PFD Monitor interpretation Establish and ratify a subject-matter-expert framework, contact process and investigation-team mapping for patient safety investigations.
Verbatim wording from the response “Having provided the rationale for the way in which beds are allocated, and processes in place for management and oversight of this, we acknowledge that analysis within our investigation could have been different. PCFT have identified a Trust wide risk in relation to ‘...a lack of MDT and SME involvement in patient safety investigations’. The risk specified that ‘If the correct MDT representation in investigation teams and subject matter expert involvement does not provide structured involvement in investigation, then the investigations may not capture correct learning, may have poor actions and the investigation may not lead to improved patient outcomes and appropriate response for patients, carers and staff’ (risk ID 2513. Score likelihood-3x consequence 4=12).” Source location Response from Pennine Care 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 Improve MDT ward-round documentation to capture patient and carer views, including mandatory use of the ward-round document.
Verbatim wording from the response “We have initiated trust-wide improvement work to ensure Multi-Disciplinary Team (MDT) documentation reliably captures patient and carer views. The identified aims of this are to:” Source location Response from Pennine Care 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 Review and develop the repatriation standard operating procedure for consistent, clinically appropriate patient transfers.
Verbatim wording from the response “As a Trust however, we acknowledge the importance of patient choice, of carer access to their loved ones and the importance for some patients of the continuity of care. To clearly articulate the process and to deliver consistency for patients we are therefore reviewing our Standard Operating Procedures for the process of” Source location Response from Pennine Care 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 Refresh and operate Central Safety Summit terms of reference to oversee appropriate participation in patient safety investigations.
Verbatim wording from the response “The Quality teams for all investigations (Patient Safety Incident Investigation; PSII) have identified subject matter experts to support in the PSII process moving forward and this is being monitored through the Network Quality and Safety Panels and through Central Safety Summit.” Source location Response from Pennine Care 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 Using Trust-wide beds rather than waiting for a local bed is considered safer because delayed admission and ward transfers may cause greater harm.
Verbatim wording from the response “Our patient flow team support the process for admission and will work hard to ensure a continuity of care where possible. The clinical decision to admit a patient is always based on the nature and degree of the presenting risk and that to delay an admission until a locality bed is available, may present the patient and their family an intolerable risk and further potential harms of waiting at home. Once the gatekeeper makes the referral, they will be told by patient flow team where the available bed is. Its then up to the gatekeeper to have that conversation / assessment with the patient/patients family if a local bed isn't available for them and to assess and judge on balance the admission to the local bed or another within the Trust.” Source location Response from Pennine Care NHS Foundation Trust
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9 Oct 2025 Derek Crowther · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Lack of contemporaneous digital recording of observations on wards View source Failure to ensure that clinical staff are up to date with required Life Support training before undertaking shifts View source
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AI-generated summary
Derek Crowther · 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
Derek Crowther died on 16 December 2024 on the Saffron Unit, The Meadows, Stockport, as a consequence of complications arising from cerebral amyloid angiopathy. The concerns identified were that a registered nurse was not up to date with mandatory Intermediate Life Support training and that observations were not being recorded contemporaneously through a digital system, creating potential risks in monitoring and recording deteriorating patients.
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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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of contemporaneous digital recording of observations on wards
Wider context from the report “2. Whilst the Court heard evidence as to relevant changes made to the Trust’s Observations Policy since Mr Crowther’s death, I am concerned that despite having an Electronic Patient Records system, there is currently no mechanism in use on the wards for contemporaneous digital recording of observations . I am concerned that an ongoing risk of future deaths arises from this position, in the view of the potential for such systems to accurately record timings of observations, facilitate trend analysis (particularly in the context of a deteriorating patient), and reduce the potential for errors, either arising from incorrect / unclear manual recording of observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that clinical staff are up to date with required Life Support training before undertaking shifts
Wider context from the report “1. The Court heard evidence that a registered nurse working on the Unit at the time of Mr Crowther’s death was not up to date with Intermediate Life Support (‘ILS’) training, despite this being termed ‘mandatory’. Having heard evidence from the Trust’s Clinical Excellence Lead for Older Peoples’ Services, I am concerned that instances continue to arise across the Trust whereby clinical staff are undertaking shifts despite not being up to date with the required level of Life Support training .
” 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 Work with Greater Manchester Mental Health colleagues to share learning and progress and inform development of the Trust’s electronic-observations system.
Verbatim wording from the response “integrity would be maintained. We are working closely with colleagues at GMMH, sharing learning and progress to inform our project and ensure we are able to implement an effective system at PCFT.” Source location Response from Pennine Care 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 Escalate non-attendance at booked ILS courses to Ward Managers and Network Quality Leads to address attendance barriers and improve compliance.
Verbatim wording from the response “Increased training capacity has been created by ensuring additional ILS training sessions have been made available. This has increased capacity and reduced waiting times for staff who need to book onto available training. Timetabling of training has been adjusted to improve access for ward-based staff. The Trust is also addressing non-attendance on ILS training, which is recognised to impact on compliance rates. Non-attendance on a booked course is escalated to Ward Managers and Network Quality Leads to support awareness but also understanding of the underlying causes or reasons why staff could not attend as planned.” Source location Response from Pennine Care 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 Require and daily-monitor at least one ILS-trained nursing staff member on every inpatient ward shift, escalating staffing gaps.
Verbatim wording from the response “Each ward is required to have at least one ILS trained member of nursing staff on every shift, including nights and weekends. Compliance with this requirement is monitored daily through Safer Staffing meetings, with escalation where gaps arise to ensure an ILS trained staff member is available for all shifts on every inpatient ward across the Trust.” Source location Response from Pennine Care 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 Develop, configure, test and pilot an electronic observations app incorporating offline capability for reliable observation recording.
Verbatim wording from the response “The Trust also established an Enhanced Therapeutic Observations of Care (ETOC) Task and Finish Group in March 2025. One of the workstreams within that group is the development of an electronic observations (eObs) app. This response will provide additional information pertaining to that workstream in addition to the information provided previously regarding the broader work of the group around, policy, training, culture and improvement. The development of an eobs app is just one element of that workplan. The build and configuration work has began on the app. This will be ready for testing by March 2026 and pilot of the app commenced in April 2026. At this stage we are unable to give a full implementation go live date Trust wide but can update you in our progress as the pilot progresses and concludes.” Source location Response from Pennine Care 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 Incorporate ILS compliance into ward rota planning to release staff for refresher training while maintaining appropriate staffing.
Verbatim wording from the response “ILS compliance is being incorporated into ward rota planning to ensure wards are appropriately staffed whilst simultaneously releasing those staff who require refresher training, which will in turn lead to an increase in compliance. The Trust is extending ILS training to additional clinical staff groups such as Bank staff and trainee doctors to increase resilience and the number of ILS trained staff present on the ward on a shift.” Source location Response from Pennine Care 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 Provide additional ILS training sessions and adjust timetables to increase capacity, improve ward-staff access and reduce booking delays.
Verbatim wording from the response “Increased training capacity has been created by ensuring additional ILS training sessions have been made available. This has increased capacity and reduced waiting times for staff who need to book onto available training. Timetabling of training has been adjusted to improve access for ward-based staff. The Trust is also addressing non-attendance on ILS training, which is recognised to impact on compliance rates. Non-attendance on a booked course is escalated to Ward Managers and Network Quality Leads to support awareness but also understanding of the underlying causes or reasons why staff could not attend as planned.” Source location Response from Pennine Care 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 Increase the Trust-wide ILS compliance target to 85% and monitor compliance through mandatory-training dashboards and governance reporting.
Verbatim wording from the response “compliance and availability of training, which is overseen within our Resuscitation Committee but also reported as part of our management structures and governance meetings.” Source location Response from Pennine Care 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 Extend ILS training to Bank staff and trainee doctors to increase the number of trained staff available on ward shifts.
Verbatim wording from the response “ILS compliance is being incorporated into ward rota planning to ensure wards are appropriately staffed whilst simultaneously releasing those staff who require refresher training, which will in turn lead to an increase in compliance. The Trust is extending ILS training to additional clinical staff groups such as Bank staff and trainee doctors to increase resilience and the number of ILS trained staff present on the ward on a shift.” Source location Response from Pennine Care 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 The Trust cannot rely on the existing GMMH eObservations app because its lack of offline capability may compromise data integrity during Wi-Fi outages.
Verbatim wording from the response “We understand a question was asked in relation to the eObs app in place at Greater Manchester Mental Health NHS Foundation Trust (GMMH) and the ability for the Trust to adopt this. Whilst GMMH has been able to implement therapeutic observations on some of their wards, which had Wi-Fi upgrades, there are challenges still with their coverage. GMMH are currently not utilising 'offline' capability, which has been identified as key requirement for our e-Obs solution, given feedback to date and the lessons that have been learnt at GMMH. Without 'offline' capability we cannot guarantee that should there be a drop in Wi-Fi connection; data” Source location Response from Pennine Care 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 A Trust-wide eObservations implementation date cannot yet be provided while pilot testing and evaluation remain ongoing.
Verbatim wording from the response “The Trust also established an Enhanced Therapeutic Observations of Care (ETOC) Task and Finish Group in March 2025. One of the workstreams within that group is the development of an electronic observations (eObs) app. This response will provide additional information pertaining to that workstream in addition to the information provided previously regarding the broader work of the group around, policy, training, culture and improvement. The development of an eobs app is just one element of that workplan. The build and configuration work has began on the app. This will be ready for testing by March 2026 and pilot of the app commenced in April 2026. At this stage we are unable to give a full implementation go live date Trust wide but can update you in our progress as the pilot progresses and concludes.” Source location Response from Pennine Care NHS Foundation Trust
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20 Aug 2025 Masood Hamid · Prevention of Future Deaths report Manchester North
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Concerns raised 4 Ineffective investigation of deaths of detained patients View source Lack of coordinated planning for least-distressing patient transport View source Ineffective learning from deaths of detained patients View source Ineffective communication between police and ambulance services during transport assistance View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Masood Hamid · 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
Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.
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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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective investigation of deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983 . As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated planning for least-distressing patient transport
Wider context from the report “1. There was a lack of planning or consideration between all those involved in his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital . This in full knowledge that any move would likely cause distress to a patient with dementia and physical health issues.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective learning from deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983. As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between police and ambulance services during transport assistance
Wider context from the report “3. There was ineffective communication between GMP and NWAS between 21:28 hours and 23:45 which delayed the deployment of officers to assist NWAS staff with the transportation of the deceased. This delay meant a prolonged period of distress and agitation which contributed to the stress placed on the deceased.
” 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 Ensure patient-specific conveyance information is shared through patient-flow and bed-management processes.
Verbatim wording from the response “be shared more easily, as part of the regular bed management meetings, which are held every day, at three different intervals. As you know, the responsibility for conveyance when a bed is identified lies with the Local Authority, so the Trust cannot always influence decision making within this area. We will, however, ensure information sharing does take place to assist decision making which is patient centred and considerate of known needs or requirements.” Source location Response Pennine Care 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 Review governance and decision-making around selecting and approving the learning review after the death.
Verbatim wording from the response “At the time of Mr Hamid’s death, and when the SWARM Huddle was completed and progressed through our approval processes, some of the information that became apparent in inquest disclosure and subsequent evidence heard during the hearing was not known. As a consequence, the Executive Director of Nursing, Quality and AHP’s has commissioned a review of the governance and decision making around which type learning review was commissioned and undertaken following Mr Hamid’s sad death. This is being undertaken by the Head of Quality in our Tameside and Glossop Care Hub. This is to ensure this is considered independently of the Care Hub and Network in which the incident took place. As” Source location Response Pennine Care NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider and decide whether to change the process for reassessing learning reviews when additional information becomes available.
Verbatim wording from the response “It is possible that consideration of a change in process in how we assess if learning reviews are still effective in identifying learning when more information is made available, could be implemented. A decision around this will be made once we have an outcome from the review, which is expected by the end of November 2025. I would be happy to share the outcome of this review and any associated recommendations and actions that are identified once these are available.” Source location Response Pennine Care 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 Request Oldham Local Authority to review its AMHP referral form to include useful conveyance information.
Verbatim wording from the response “Our Head of Quality has also met with colleagues from Oldham Local Authority to discuss this further. She requested that the Local Authority team review their AMHP referral form so that additional useful information, particularly around conveyance, is included on the document for their consideration. Again, we are not able to enforce this, but it is hoped that this recommendation is recognised as a positive step to ensure the patient and their needs are at the centre of this process.” Source location Response Pennine Care 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 Participate in the Safeguarding Adult Review and act on learning identified through it.
Verbatim wording from the response “Since Mr Hamid’s inquest concluded, there has been a Safeguarding Adult Review commissioned by the Oldham Safeguarding Adult Partnership. Pennine Care NHS Foundation Trust will be participating in that review and will continue to fully engage with that process and act upon any learning identified as part of the review. This is ongoing at the point of sharing this letter with you.” Source location Response Pennine Care 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 The Trust cannot enforce changes to the Local Authority’s AMHP referral form, including adding information about conveyance.
Verbatim wording from the response “Our Head of Quality has also met with colleagues from Oldham Local Authority to discuss this further. She requested that the Local Authority team review their AMHP referral form so that additional useful information, particularly around conveyance, is included on the document for their consideration. Again, we are not able to enforce this, but it is hoped that this recommendation is recognised as a positive step to ensure the patient and their needs are at the centre of this process.” Source location Response Pennine Care 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 daily bed management meetings provide established mechanisms for sharing patient information to support patient-centred conveyance decisions.
Verbatim wording from the response “The member of staff reflected on this and identified that he did not share this information directly with the Approved Mental Health Professional (AMHP) Service. They felt that in future, they would endeavour to ensure this type of personal information was shared. From a system perspective, there are robust mechanisms in place surrounding patient flow in which information like this can” Source location Response Pennine Care 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 Including additional patient information would not have changed the transfer decision because the patient presented a serious risk to others.
Verbatim wording from the response “Following review and discussion with Oldham Local Authority, it is not believed that the inclusion of this information would have changed the decision made to transfer Mr Hamid from the care home to hospital. This was because Mr Hamid was detained under Section 2 of the Mental Health Act as he presented as a risk to other people, including residents and colleagues within the care home. Mr Hamid had presented as a risk that day to others and it was only later in the day that he had appeared to have calmed with the use of PRN medications.” Source location Response Pennine Care 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 The Local Authority is responsible for arranging patient conveyance when a hospital bed is identified, limiting the Trust’s influence over decisions.
Verbatim wording from the response “be shared more easily, as part of the regular bed management meetings, which are held every day, at three different intervals. As you know, the responsibility for conveyance when a bed is identified lies with the Local Authority, so the Trust cannot always influence decision making within this area. We will, however, ensure information sharing does take place to assist decision making which is patient centred and considerate of known needs or requirements.” Source location Response Pennine Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that a further investigation was required because no evidence then linked the death to problems in its care.
Verbatim wording from the response “Since you identified the above concern, further analysis and reflection was undertaken in the Trust’s Central Safety Summit. This was focused on the decision to undertake a SWARM Huddle, of its conclusion and closure, opposed to the commissioning of a further learning review, such as a Patient Safety Incident Investigation (PSII). As part of these discussions the Trust’s PSIRF Policy was consulted which indicates that a PSII should be undertaken for ‘Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity Act (2005) applies, where there is reason to think that the death may be linked to problems in care.’ At the time of Mr Hamid’s death, there was nothing to show following the completion of the learning review that Mr Hamid’s death was linked to any problems in relation to the care provided to Mr Hamid from the Trust.” Source location Response Pennine Care NHS Foundation Trust
Open published response
18 Sep 2024 David Paul Power · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Exclusion of referrals from talking therapies based on a stability policy View source Lack of evidence that SPOE referral for MDT consideration is embedded in team practice View source Lack of auditing of SPOE referral for MDT consideration View source Lack of shared definitions of stability across the talking therapies pathway 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
David Paul Power · 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
David Paul Power, aged 28, intentionally took his own life by hanging on 7 August 2023 after a decline in his mental health. The report found that his deterioration was exacerbated by a letter incorrectly discharging him from a neighbourhood mental health team. Concerns included differing definitions of “stability” between services, which prevented access to talking therapies, and a lack of evidence that subsequent team actions had been embedded or audited.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Exclusion of referrals from talking therapies based on a stability policy
Wider context from the report “1. I am concerned that the Home Treatment Team referred David to a service to receive psychological/ talking therapies. This was a team called Healthy Minds. This referral took place when the HTT discharged David as they considered him to be sufficiently ‘stable’ under their HTT definitions.
2. However, David was not accepted for by Healthy Minds because they had a policy that they would not accept referrals for individuals who they did not consider to be sufficiently ‘stable’ under their Healthy Minds policies .
3. One of the criteria for stability was that the individual should not have attempted suicide or serious self-harm for 3 months . This was not known to the HTT at the time they made the referral. The effect of this policy meant that David was not accepted for this service, despite him making clear to services that talking therapies was what he needed most to support his mental health.
4. I heard evidence that this policy remains in place within NHS Talking Therapies (the successor to Healthy Minds), but is currently under review. I did not hear any evidence as to if or when it will change.
5. I am concerned that the lack of shared understanding and definition of ‘stability’ for patients along the talking therapies pathway creates a risk of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence that SPOE referral for MDT consideration is embedded in team practice
Wider context from the report “6. I heard evidence that since David’s death, the HTT has emailed at the staff at the Tameside HTT to re-iterate the importance of referring cases to SPOE meetings for MDT consideration, and that this has been discussed in two team meetings before February 2024. There was no evidence before me of whether this has been embedded or audited within the team to reduce the risk of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of SPOE referral for MDT consideration
Wider context from the report “6. I heard evidence that since David’s death, the HTT has emailed at the staff at the Tameside HTT to re-iterate the importance of referring cases to SPOE meetings for MDT consideration, and that this has been discussed in two team meetings before February 2024. There was no evidence before me of whether this has been embedded or audited within the team to reduce the risk of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared definitions of stability across the talking therapies pathway
Wider context from the report “1. I am concerned that the Home Treatment Team referred David to a service to receive psychological/ talking therapies. This was a team called Healthy Minds. This referral took place when the HTT discharged David as they considered him to be sufficiently ‘stable’ under their HTT definitions .
2. However, David was not accepted for by Healthy Minds because they had a policy that they would not accept referrals for individuals who they did not consider to be sufficiently ‘stable’ under their Healthy Minds policies .
3. One of the criteria for stability was that the individual should not have attempted suicide or serious self-harm for 3 months. This was not known to the HTT at the time they made the referral. The effect of this policy meant that David was not accepted for this service, despite him making clear to services that talking therapies was what he needed most to support his mental health.
4. I heard evidence that this policy remains in place within NHS Talking Therapies (the successor to Healthy Minds), but is currently under review. I did not hear any evidence as to if or when it will change.
5. I am concerned that the lack of shared understanding and definition of ‘stability’ for patients along the talking therapies pathway creates a risk of future deaths.
” 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 Home Treatment Team referral and discharge processes requiring onward-referral outcomes and care pathways to be discussed before discharge.
Verbatim wording from the response “‘If the service user requires a referral to other community services such as Living well, and talking therapies, then the practitioner must complete a referral form online and send to appropriate service. This will then be discussed the week after, during their daily huddles, where they discuss each patient who has been referred and their suitability. Patients are not to be discharged from HTT until the outcome of the referral has been discussed and agreed. For service users where a longer term and/or complex care has been indicated, the practitioner can refer to the single point of entry meeting with the corresponding CMHT; this consists of various practitioners and the sector Consultant based on the patient’s GP location.’” Source location Response from Pennine Care 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 Finalize, discuss and share the NHS Talking Therapies operating procedure with relevant teams.
Verbatim wording from the response “The draft SOP to outline the PCFT’s NHS TT Service and how they operate, is awaiting final review by the Trust’s Quality Group scheduled to take place on 22 November 2024. It will also be taken to the Psychotherapeutic Committee for discussion and then shared with relevant teams.” Source location Response from Pennine Care 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 Screen referrals for engagement and safety, assess current stability, and monitor referral decisions through practitioner rationales and managerial checks.
Verbatim wording from the response “The NHS TT Step 2 & 3 is part of primary care, with a focus on needs-led care. The Standard Operating Procedure (SOP) will continue to outline the position that any current and significant self-harm will remain an obstacle to engaging in current therapy but will provide clarification that individuals will be assessed based on current stability, not past conditions, ensuring a streamlined process. Referrals will assess the patient's ability to engage and ensure their safety before admission onto the waiting list for therapy. NHS TT will refer to the appropriate service if their service does not meet an individual’s needs and this will be monitored and checked by the NHS TT Leads and Service Manager via clear rationale that has been provided by the practitioner who has screened the referral.” Source location Response from Pennine Care 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 Remove recent statutory mental-health contact and recent failed-suicide-attempt criteria from NHS Talking Therapies referral screening.
Verbatim wording from the response “The Trust has ensured that our lead for NHS TT has reviewed the SOP and the following clauses (‘Recent contact (less than 3 months) with other statutory mental health services’ and ‘Recent history of failed suicide attempt (less than 3 months)’) have been removed and will no longer be part of the screening as to whether a referral will be accepted or declined.” Source location Response from Pennine Care 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 Living Well staff reflection and learning sessions on language, stability terminology and person-centred care.
Verbatim wording from the response “The Trust recognises that these terms used do not reflect or align with person centred care approach, nor are these helpful to our service users, or their carers, particularly when understanding a service users’ care journey and why decisions were made. As a Trust we are taking action to support practitioners to change this aspect of describing a person’s current condition. The Living Well services, will be holding reflection and learning sessions for our staff in relation to language, with particular focus on these terms and what they mean and how their use impacts providing person-centred care. These will take place from end of January 2025 onwards.” Source location Response from Pennine Care 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 Provide NHS Talking Therapies training to Living Well, Home Treatment Team and emergency liaison colleagues on the revised service procedure.
Verbatim wording from the response “The Trust’s NHS TT Teams will provide training to Living Well, HTT and our A&E Liaison colleagues to increase knowledge of how the TT services work in line with the new service SOP, this will foster and develop a much clearer shared understanding of the phrase ‘stable’.” Source location Response from Pennine Care 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 Audit monthly whether Home Treatment Team discharges and onward referrals comply with the revised operating procedure.
Verbatim wording from the response “The HTT Service Manager and Team Manager have a responsible and accountable role for checking and auditing monthly (commenced 2024) that discharges and onward referrals are managed in accordance with the new SOP.” Source location Response from Pennine Care Trust
Open published response
12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to identify absence of NHS community services when formulating the ongoing plan View source Failure to open the four standard care plans during inpatient stay View source Failure to commence and complete a safety plan during admission and before discharge View source Failure to engage the local Home Based Treatment Team before discharge View source Lack of ability to access relevant parts of medical records View source Failure of consultant-to-consultant communication across NHS and private care View source Failure to investigate nursing staff and determine whether care failures reflect individual or system failure View source Failure to consult treating consultants across Priory locations View source Failure to make a 48-hour post-discharge follow-up call View source Failure to consider regulatory referral of individuals View source Failure to undertake an internal review for learning from the admission View source Failure to discuss the reasons for rapid relapse with the patient View source Failure to provide crisis information at discharge View source Failure to complete the discharge clinical entry and risk assessment View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr David Thompson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify absence of NHS community services when formulating the ongoing plan
Wider context from the report “2. At the time of his appointment in January 2024 Mr Thompson was not under any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to open the four standard care plans during inpatient stay
Wider context from the report “6. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to commence and complete a safety plan during admission and before discharge
Wider context from the report “1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage the local Home Based Treatment Team before discharge
Wider context from the report “2. There was no engagement prior to discharge with the local Home Based Treatment Team .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ability to access relevant parts of medical records
Wider context from the report “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information . Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of consultant-to-consultant communication across NHS and private care
Wider context from the report “1. There was a complete absence of any Consultant – Consultant discussions or communication , given this patient was receiving care from both the NHS and privately .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate nursing staff and determine whether care failures reflect individual or system failure
Wider context from the report “7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out . There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure . Nor was consideration given to whether any individuals should be reported to their regulatory body.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult treating consultants across Priory locations
Wider context from the report “3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make a 48-hour post-discharge follow-up call
Wider context from the report “4. There was no 48 hour follow up call to Mr Thompson following his discharge , as per Priory Policy.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider regulatory referral of individuals
Wider context from the report “7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an internal review for learning from the admission
Wider context from the report “3. No internal review was undertaken of Mr Thompsons admission within the Priory Altrincham to consider whether there was any learning
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss the reasons for rapid relapse with the patient
Wider context from the report “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide crisis information at discharge
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the discharge clinical entry and risk assessment
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
” 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 Provide five Band 7 Out of Area Practitioners to monitor private out-of-area placements, coordinate providers and support discharge planning.
Verbatim wording from the response “To ensure the quality and consistency of the care of Pennine Care patients who are placed in an out of area private bed, an Out of Area Practitioner is responsible for monitoring the inpatient stay, linking in with the relevant providers and inpatient operational leads to ensure all patients receive support and discharge planning as required. The Out of Area Practitioner is a senior mental health practitioner (Band 7) who sits within the Patient Flow Team. They act as a case manager for that patient including attending ward rounds, keeping key professionals (including all Consultants) updated and involvement in repatriation and discharge planning. There are five of these practitioners within the organisation and each practitioner covers one of the five boroughs in which services are commissioned.” Source location Response from Pennine Care NHS
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 Liaise with Medical Directors of Priory, Elysium and Cygnet to address communication failures collaboratively.
Verbatim wording from the response “The organisation’s Medical Director will also liaise with the Medical Directors of all the private providers that Pennine Care patients are known to be placed. Contact will be made with the Priory, Elysium and Cygnet to raise the profile of this identified issue and to work collaboratively to ensure that this issue does not occur again.” Source location Response from Pennine Care NHS
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 formal guidance on sharing correspondence when patients receive NHS and private-provider care.
Verbatim wording from the response “In order to provide assurance that Pennine Care NHS Foundation Trust’s doctors are also adhering to this guidance formal communication has been sent to all doctors within the organisation from our Medical Director reminding them of this guidance and the GMC’s stipulation that all doctors must follow this. It also highlights this case and asks the doctors to take particular care if a patient is receiving treatment from both an NHS and private provider and that the private provider will also be copied into any correspondence.” Source location Response from Pennine Care NHS
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 doctor who sees the patient, rather than the GP, is responsible for sharing clinic correspondence with other care providers.
Verbatim wording from the response “It was ████████’s evidence that the clinic letter was shared with David’s GP and he expected the GP to then share this information with all other care providers. This is not the responsibility of the GP but the responsibility of the doctor who has seen the patient. This evidence was factually incorrect and it is the view of the organisation’s Medical Director, ████████, that this is in breach of the GMC’s Good Medical Practice, which all doctors must follow.” Source location Response from Pennine Care NHS
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 organisation disputes that Consultant-to-Consultant communication failed through its omission, stating it was unaware of the private outpatient appointment.
Verbatim wording from the response “The organisation was not aware that David attended an outpatient appointment with ████████ at the Priory Hospital, Altrincham and therefore the opportunity for Consultant to Consultant communication to take place did not happen. The organisation’s expectation is for ████████ to copy the organisation into David’s clinic letter as per the section of ‘Contributing to continuity of care’ within the General Medical Council’s (GMC) ‘Good Medical Practice.’ The guidance states:” Source location Response from Pennine Care NHS
Open published response
29 May 2024 Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 19 Inadequate management structure and oversight in the health and wellbeing college View source Failure to comply with GDPR in the health and wellbeing college View source Inadequate safeguarding provisions in health and wellbeing colleges View source Insufficient probation staffing capacity View source High proportion of probation officers with limited service and experience View source Limited information-sharing protocols between probation and partner services View source Lack of professional curiosity by senior GMP officers View source Poor-quality GMP investigations and reports View source Insufficient staffing of sexual offender management units View source Poor-quality investigations failing to generate organisational learning View source Failure to provide adequate supervision and support to newly qualified probation staff View source Insufficient professional curiosity among staff dealing with high-risk offenders View source Ineffective information-sharing protocols in health and wellbeing colleges View source Sexual offender management caseloads exceeding safe levels View source Insufficiently clear and understood risk-management protocols in health and wellbeing colleges View source Failure to escalate investigation reports for senior consideration View source Referrals to health and wellbeing services without risk-management protocols View source Inadequate systems for managing risk in the health and wellbeing college View source Lack of an information-sharing protocol between the health and wellbeing college and probation View source See 16 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. 15
Action
Apply a safeguarding policy covering College students when staff identify safeguarding concerns or incidents.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Implement a standard operating procedure governing referral, enrolment, clinical-system checks, external risk information, and managerial authorisation for College students.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Conduct a tabletop review of the investigation process and identify learning on investigation triggers, recording, scope, investigator capability, and quality assurance.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Apply documented onsite risk controls, including recording concerns, checking student files against registers, and verifying online registers before classes.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Maintain safeguarding training compliance, verify staff compliance before the September term, and provide scheduled and termly safeguarding learning sessions.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024. View source
Action
Introduce a Central Safety Summit and associated governance processes for significant patient-safety investigations, with Trust Board and Quality Committee oversight.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Commission a training programme to enhance staff capability in reviewing and learning from patient-safety incidents.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024. View source
Action
Establish information-sharing requirements for students, clinical teams, external agencies, and College partners through permissions, risk liaison, and signed partnership agreements.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Operate twice-daily staff briefings and termly College meetings to share course, staffing, risk, and other operational information.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Establish a controlled generic College email account with defined access, daily checking, welfare and risk escalation routes, and absence cover.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Disseminate the updated College standard operating procedures through staff email briefing, team briefings, and accessible electronic and hard-copy storage.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Complete an external review of the College’s risk-management issues and use its findings to identify further development opportunities.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024. View source
Action
Report safeguarding compliance data quarterly through the Trust’s governance systems.
Stated plannedThe respondent said that this action was planned when they made their response on 31 May 2024. View source
Action
Integrate investigation-process recommendations into the Trust’s organisational change under the Patient Safety Incident Response Framework.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024. View source
Action
Run regular information-governance sessions for College staff and volunteers on safe sharing of information from other agencies.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source See 12 more actions
×
AI-generated summary
Elizabeth Sarah Jayne McCann · 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
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational learning.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate management structure and oversight in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight , lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with GDPR in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate safeguarding provisions in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient probation staffing capacity
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads . This was due to challenges in recruiting sufficient staff . The evidence was that there is still a national shortage of probation officers . Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation High proportion of probation officers with limited service and experience
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited information-sharing protocols between probation and partner services
Wider context from the report “4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited . Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity by senior GMP officers
Wider context from the report “8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt . It was unclear as to why senior officers were unsighted .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor-quality GMP investigations and reports
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing of sexual offender management units
Wider context from the report “5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units . As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor-quality investigations failing to generate organisational learning
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed . This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate supervision and support to newly qualified probation staff
Wider context from the report “2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers . Without that supervision performance issues identified by the trackers were not being tackled . Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high . This was being addressed but was only achievable if sufficient senior staff were retained.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional curiosity among staff dealing with high-risk offenders
Wider context from the report “9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective information-sharing protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Sexual offender management caseloads exceeding safe levels
Wider context from the report “6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level . The numbers in the unit were increasing but the caseloads were still high.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear and understood risk-management protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place . There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate investigation reports for senior consideration
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report . The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Referrals to health and wellbeing services without risk-management protocols
Wider context from the report “3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate systems for managing risk in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an information-sharing protocol between the health and wellbeing college and probation
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation , the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Apply a safeguarding policy covering College students when staff identify safeguarding concerns or incidents.
Verbatim wording from the response “If any safeguarding concerns arise, these should be reported to a College Lead immediately, who will act accordingly. If necessary, guidance/further advice will be sought from the Trust safeguarding team.” Source location Response from Pennine Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standard operating procedure governing referral, enrolment, clinical-system checks, external risk information, and managerial authorisation for College students.
Verbatim wording from the response “The College has a new Standard Operating Procedure within which there is a clearly articulated protocol for the referral and enrolment process for any member of the public, referring agency or clinical team referral. This protocol has a stepped approach to risk management and includes cross-reference checks with Trust clinical systems (PARIS our Electronic Patient Record system and incident reporting systems). Any referral by an external agency, such as the probation or service [e.g., third sector] will be required to share risk information that is known about the person.” Source location Response from Pennine Care
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 a tabletop review of the investigation process and identify learning on investigation triggers, recording, scope, investigator capability, and quality assurance.
Verbatim wording from the response “As part of the reflections immediately post inquest, a tabletop review of the process followed in this case was requested by the Executive Director of Quality, Nursing and Healthcare Professionals, who had taken up his post in the weeks before the inquest. This review was led by a member of the Director team and identified learning.” Source location Response from Pennine Care
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 Apply documented onsite risk controls, including recording concerns, checking student files against registers, and verifying online registers before classes.
Verbatim wording from the response “2. Record any conversations or discussions regarding the above, in the student’s individual paper file on the notes sheet. This should be signed and dated, with the time of the note entry recorded.” Source location Response from Pennine Care
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 Maintain safeguarding training compliance, verify staff compliance before the September term, and provide scheduled and termly safeguarding learning sessions.
Verbatim wording from the response “All staff working within the Health and Wellbeing College are up to date with their safeguarding training - level 2 (College management – level 3). This is monitored by the Health and Wellbeing College Leads, in liaison with the Volunteering Team and the Temporary Staffing Team. All staff compliance will be checked before the start of the September term.” Source location Response from Pennine Care
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 Central Safety Summit and associated governance processes for significant patient-safety investigations, with Trust Board and Quality Committee oversight.
Verbatim wording from the response “In order to facilitate the recommendations, the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes into our agreed structure which should support a more robust process for the most significant patient safety investigations. One of these is a Central Safety Summit, with an approved scope and purpose agreed at Trust Board level, with reporting into our Quality Committee to ensure continuous oversight at a Non-Executive Director level.” Source location Response from Pennine Care
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 a training programme to enhance staff capability in reviewing and learning from patient-safety incidents.
Verbatim wording from the response “(PSIRF). As part of this, we are also commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents. This is intended to build on the existing offer available to staff, to create a robust system and pool of those able to undertake this responsibility effectively and efficiently.” Source location Response from Pennine Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish information-sharing requirements for students, clinical teams, external agencies, and College partners through permissions, risk liaison, and signed partnership agreements.
Verbatim wording from the response “As outlined in our earlier response, since Elizabeth’s death, the College has developed a standard operating procedure that outlines the steps and processes required by College leads and administrators in relation to information received by the College and the steps required for every student’s successful enrolment to commence. These checks include self-disclosure by students relating to activity and engagement with other agencies in addition to checks against internal clinical systems.” Source location Response from Pennine Care
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 Operate twice-daily staff briefings and termly College meetings to share course, staffing, risk, and other operational information.
Verbatim wording from the response “The College shares information within the staff group and operates 2 x 10-minute briefings each day, at the following times:” Source location Response from Pennine Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a controlled generic College email account with defined access, daily checking, welfare and risk escalation routes, and absence cover.
Verbatim wording from the response “The College team have worked to develop and share protocols in relation to information governance with the staff group. These include the creation of a generic email account, access to the generic email account, standardised out of office for the account and escalation processes in relation to information received to the generic email account, an extract of which is provided here for assurance:” Source location Response from Pennine Care
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 Disseminate the updated College standard operating procedures through staff email briefing, team briefings, and accessible electronic and hard-copy storage.
Verbatim wording from the response “The new Standard Operating Procedures for the College were shared through a briefing note e-mail of 17th April 2024 regarding the updated version of the Standard Operating Procedure (SOP) and the reminder noted in the team brief notes on 3rd July 2024. This is stored within the shared electronic folder which all staff can access, with a hard copy on file in the office for reference.” Source location Response from Pennine Care
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 Complete an external review of the College’s risk-management issues and use its findings to identify further development opportunities.
Verbatim wording from the response “Prior to receipt of the Regulation 28 notice, the Executive team here commissioned an external review of the College. This is currently concluding with the outcome anticipated before 31 July 2024. The Network Director of Quality, Nursing and Health Professionals for our South Network (████████) is working with the team at the College in relation to all of the issues highlighted by the internal investigation report, the evidence heard at Inquest and from the early findings of the external review.” Source location Response from Pennine Care
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 Report safeguarding compliance data quarterly through the Trust’s governance systems.
Verbatim wording from the response “The College will report quarterly compliance data for safeguarding through the Trust’s established governance systems.” Source location Response from Pennine Care
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 Integrate investigation-process recommendations into the Trust’s organisational change under the Patient Safety Incident Response Framework.
Verbatim wording from the response “These findings were received and accepted by our new Executive Director of Quality, Nursing and Health Professionals who is being supported by the Interim Head of Patient Safety and Clinical Effectiveness to dovetail these recommendations into our broader change in organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework” Source location Response from Pennine Care
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 Run regular information-governance sessions for College staff and volunteers on safe sharing of information from other agencies.
Verbatim wording from the response “Working with the Information Governance Leads the College has established regular sessions with all staff and volunteers at the College to remind them of the importance of the General Data Protection Regulation rules when information is shared from other agencies.” Source location Response from Pennine Care
Open published response
30 Nov 2023 Donna Marie Donnellan · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service View source Lack of clarity about the role and remit of the Mental Health Liaison Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Donna Marie Donnellan · 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
Donna Marie Donnellan had a long-standing history of disordered eating, severe weight loss and peripheral neuropathy. She was found deceased at home on 10 October 2022, and the investigation recorded death from complications arising from malnutrition likely due to an undiagnosed atypical eating disorder. Concerns included unclear roles between acute clinicians and the Mental Health Liaison Team, and a lack of understanding about referral pathways to specialist eating disorder services.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service
Wider context from the report “2) There was a lack of understanding as to the pathways available to the acute clinicians for making a referral/seeking advice from the Specialist Eating Disorder Service ie the Willows.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the role and remit of the Mental Health Liaison Team
Wider context from the report “1) There was a lack of understanding between the Acute Trust clinicians and the Mental Health Trust as to the role of the Mental Health Liaison Team. Clarity is required as to whether the MHLT when asked to review a patient by the acute clinicians are reviewing so as to (i) make a diagnosis of an eating disorder or (ii) assess and assist in the consideration as to whether the Mental Health Act can be used to treat someone if they are refusing treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.
Verbatim wording from the response “Teams at Pennine Care NHS Foundation Trust have worked closely with colleagues at the Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. We have agreed to jointly review the policy owned by Northern Care Alliance NHS Foundation Trust, Management of Medical Emergencies in Adult Patients with Eating Disorders, which provides clear guidance for staff working within the Accident and Emergency” Source location Response from Pennine Care 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 Share inquest learning and policy details with the appropriate teams through managers.
Verbatim wording from the response “As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.” Source location Response from Pennine Care 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 Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.
Verbatim wording from the response “As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.” Source location Response from Pennine Care NHS Foundation Trust
Open published response
24 Nov 2023 Teresa Chmielek · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 9 Failure to conduct meaningful multi-team discussion at screening MDT meetings View source Failure to record and confirm communication of referral rejection reasons View source Failure to record recent suicide attempts in screening MDT notes View source Failure to make direct contact with referred patients before rejecting referrals View source Lack of audit of SPoE referral management and related decision-making View source Lack of a Standard Operating Procedure for managing SPoE Older Adults referrals View source Failure to identify or recognise suicide risk during referral screening View source Lack of referral cover during SPoE Nurse absence View source Failure to discuss referrals during consultant psychiatric review View source See 6 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
Teresa Chmielek · 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
Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral decisions.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct meaningful multi-team discussion at screening MDT meetings
Wider context from the report “(2) The Court heard that the practice at the screening MDT meeting was for the SPoE Nurse to read out the contents of the referral to the Psychiatrist who would then advise on next steps. There was no evidence to show that any form of meaningful multi-team discussion took place at the screening MDT meeting
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and confirm communication of referral rejection reasons
Wider context from the report “(4) The Consultant Psychiatrist present at the MDT meeting has no recollection of discussing the referral and whilst the evidence was that a letter to the GP practice explaining the reason for rejecting the referral was generated there is no record of this letter on the Trust's electronic systems or having been received by the GP practice
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record recent suicide attempts in screening MDT notes
Wider context from the report “(1) The notes made by the SPoE Nurse for use during discussion at the screening MDT meeting did not include any reference to the report of a recent suicide attempt and the Court was not satisfied that the risk of suicide had been identified or recognised by the SPoE 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct contact with referred patients before rejecting referrals
Wider context from the report “(3) There was no direct contact between the mental health team and the Deceased (either by telephone or in person) before the decision to reject the referral was made
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of SPoE referral management and related decision-making
Wider context from the report “(7) There is currently no system by which the management of referrals into the SPoE and related decision-making are audited . As such there is a risk that poor quality decision-making is going unchecked.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a Standard Operating Procedure for managing SPoE Older Adults referrals
Wider context from the report “(6) There is currently no Standard Operating Procedure on how referrals into the SPoE Older Adults should be managed
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify or recognise suicide risk during referral screening
Wider context from the report “(1) The notes made by the SPoE Nurse for use during discussion at the screening MDT meeting did not include any reference to the report of a recent suicide attempt and the Court was not satisfied that the risk of suicide had been identified or recognised by the SPoE 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of referral cover during SPoE Nurse absence
Wider context from the report “(5) The evidence was that there is no member of staff allocated to deal with referrals when the SPoE Nurse is absent from work which means that during their absence, urgent referrals are not being reviewed .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss referrals during consultant psychiatric review
Wider context from the report “(4) The Consultant Psychiatrist present at the MDT meeting has no recollection of discussing the referral and whilst the evidence was that a letter to the GP practice explaining the reason for rejecting the referral was generated there is no record of this letter on the Trust's electronic systems or having been received by the GP practice
” Open source report
21 Jul 2023 Corinne Haslam · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness View source Failure of electronic records systems to support transfer of clinical information between mental health and physical health specialists View source Lack of clear guidance for undertaking and repeating Venous Thromboembolism risk assessments View source Barriers to obtaining physical health specialist input for mental health ward patients View source See 1 more concern
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
Corinne Haslam · 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
Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness
Wider context from the report “1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department.
Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness ;
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of electronic records systems to support transfer of clinical information between mental health and physical health specialists
Wider context from the report “2. It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems . The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa) , with an inherent risk to patient safety arising from such information being held in silos .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for undertaking and repeating Venous Thromboembolism risk assessments
Wider context from the report “3. It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism (‘VTE’) should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Barriers to obtaining physical health specialist input for mental health ward patients
Wider context from the report “1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department .
Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness;
” Open source report
16 May 2023 Carl Garry Thompson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Failure to address inadequate leave risk assessment and planning through investigation and learning View source Failure to seek lawful consultation about supported return to the ward View source Failure to use direct contact to understand identified risk factors View source Inadequate risk assessment and planning for s.17 leave View source Failure to assess how multiple risk factors combine to increase risk View source Failure to complete identified action plan actions View source Risk to physical health from resumed substance misuse after abstinence View source Failure to escalate risk information through the on-call system for medical support View source Failure to allocate a CMHT Care Coordinator during prolonged inpatient admission View source Failure to provide face-to-face CMHT assessment in line with Trust Policy View source See 7 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. 9
Action
Revisit local support for investigation authors and services to promote active review of action plans and prepare authors to evidence improvements.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Hold inpatient learning forums in addition to training meetings to reflect on shared learning, including learning from this case.
Stated plannedThe respondent said that this action was planned when they made their response on 17 May 2023. View source
Action
Improve CMHT allocation and discharge coordination through increased staffing, reduced waiting lists, weekly ward attendance and duty-worker participation in relevant ward rounds.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Develop PSIRF implementation arrangements, including updated investigation templates and support for staff completing investigations.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Provide General Drug and Alcohol brief-intervention training and awareness sessions for inpatient ward staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Raise awareness of contacting patients on leave when concerns arise through supervision and an inpatient learning forum.
Status at responseThe respondent said that this action was partly complete when they made their response on 17 May 2023. View source
Action
Raise awareness of out-of-hours escalation processes through staff supervision, trust-wide learning and a poster displayed across inpatient teams.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Share learning on documented risk assessment through supervision, consultant meetings, trust-wide dissemination and the Care Hub Quality Learning forum.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Continue booking staff onto Clinical Risk Formulation and STORM training, while monitoring uptake and compliance with essential-to-role training.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source See 6 more actions
×
AI-generated summary
Carl Garry Thompson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Carl Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address inadequate leave risk assessment and planning through investigation and learning
Wider context from the report “1. I am concerned that the jury have found that the risk assessments and risk planning for Carl’s s.17 leave in March 2023 was inadequate. This issue was not addressed in the Trusts’ internal investigation conducted by ████████ and I have not received any evidence that there have been reflections or changes following Carl’s death on this issue to reassure me that there is not a continuing risk of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek lawful consultation about supported return to the ward
Wider context from the report “2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns.
3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse.
4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl.
5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family . The review concluded that the nursing team could have escalated this information via the on-call system for further medical 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use direct contact to understand identified risk factors
Wider context from the report “2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns.
3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse.
4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl .
5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate risk assessment and planning for s.17 leave
Wider context from the report “1. I am concerned that the jury have found that the risk assessments and risk planning for Carl’s s.17 leave in March 2023 was inadequate . This issue was not addressed in the Trusts’ internal investigation conducted by ████████ and I have not received any evidence that there have been reflections or changes following Carl’s death on this issue to reassure me that there is not a continuing risk of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess how multiple risk factors combine to increase risk
Wider context from the report “2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns.
3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse .
4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl.
5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete identified action plan actions
Wider context from the report “9. ████████ gave evidence that although the Trust Review had identified a number of missed opportunities, the Trust Action plan, which contained 6 Action points was still “In progress” . ████████ was not able to identify a single action point that had been completed to date .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk to physical health from resumed substance misuse after abstinence
Wider context from the report “6. The review concluded that a risk to Carl’s physical health was present especially in view of research and evidence for substance misusers starting to use again after periods of abstaining .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate risk information through the on-call system for medical support
Wider context from the report “2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns.
3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse.
4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl.
5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate a CMHT Care Coordinator during prolonged inpatient admission
Wider context from the report “8. I am concerned that prior to his commencing leave on the 7th March, Carl had not been allocated a CMHT Care Coordinator , despite being an inpatient for over 3 months , since 31st December 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face CMHT assessment in line with Trust Policy
Wider context from the report “7. I am concerned that on the 9th March, Carl should have been seen face to face by the CMHT, in line with Trust Policy . Instead he only received a telephone call from a duty worker who had never met him .
” 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 Revisit local support for investigation authors and services to promote active review of action plans and prepare authors to evidence improvements.
Verbatim wording from the response “IR authors required to give evidence will be supported and be prepared to give evidence against the action plan demonstrating improvements in service. To this end, local support has been revisited for Investigation authors, to support active review of action plans with the Investigation author and the services involved.” Source location Response from Pennine Care 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 inpatient learning forums in addition to training meetings to reflect on shared learning, including learning from this case.
Verbatim wording from the response “Further action:
- Inpatient Learning forums have been agreed to be held in addition to training ████████ meetings to reflect on shared learning points. The learning from this case is going to be shared in a learning forum on 30/06/2023.” Source location Response from Pennine Care 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 Improve CMHT allocation and discharge coordination through increased staffing, reduced waiting lists, weekly ward attendance and duty-worker participation in relevant ward rounds.
Verbatim wording from the response “The investigation recognised that during the time period of CT’s death, CMHT was on the Trust Risk Register in relation to staffing vacancies and patients awaiting allocation. The current position is more positive with an improved staffing establishment, a reduced waiting list and CMHT is no longer on risk register.” Source location Response from Pennine Care 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 Develop PSIRF implementation arrangements, including updated investigation templates and support for staff completing investigations.
Verbatim wording from the response “- The trust is considering an updated training offer for authors of investigations with a compassionate, just culture approach.
- The Trust has a new PSIRF (Patient Safety Incident Response Framework) implementation group, this was established in February 2023 following a PSIRF trust wide Implementation planning away day. This is looking at the new framework, planning for implementation including updated Investigation templates and support for staff completing these.
- Patients Safety training is now available online for all staff to complete. As part of the new PSIRF framework additional training on supporting authors approaching investigations has been offered to staff virtually through 2023.
- The Quality team have also planned to share learning slides around preparation for Coroner’s Inquests with staff identified as Investigation authors.” Source location Response from Pennine Care 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 Provide General Drug and Alcohol brief-intervention training and awareness sessions for inpatient ward staff.
Verbatim wording from the response “████████st Drug and Alcohol service is supporting their ████████ Intervention and Development worker to commence providing General Drug ████████cohol brief intervention training for inpatient ward staff.” Source location Response from Pennine Care 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 Raise awareness of contacting patients on leave when concerns arise through supervision and an inpatient learning forum.
Verbatim wording from the response “This was identified as an action within the Investigation detailed ‘Where there are concerns expressed whilst a patient is on leave – consider making attempts to contact the patient to assess the situation.’” Source location Response from Pennine Care 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 Raise awareness of out-of-hours escalation processes through staff supervision, trust-wide learning and a poster displayed across inpatient teams.
Verbatim wording from the response “The recommendation detailed: Inpatient services to escalate concerns out of hours through appropriate out of hours support – e.g., night manager, consultant on call.” Source location Response from Pennine Care 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 Share learning on documented risk assessment through supervision, consultant meetings, trust-wide dissemination and the Care Hub Quality Learning forum.
Verbatim wording from the response “To address this point, the steps the service has taken so far are:
- Shared learning for the staff team, this has been shared via supervision and the Care Hub Quality Learning forum.
- ████████ consultant team, this has been shared via the lead ████████ patient meeting to support the importance of well-documented risk assessments.
- ████████ trust, this has been shared as trust wide learning for ████████ within the footprint to be aware of and learn from.
- Continued commitment to booking staff on the Clinical Risk Formulation ████████ STORM (suicide prevention skills) training; ward manager and service manager will monitor uptake and compliance with essential to role training.” Source location Response from Pennine Care 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 booking staff onto Clinical Risk Formulation and STORM training, while monitoring uptake and compliance with essential-to-role training.
Verbatim wording from the response “To address this point, the steps the service has taken so far are:
- Shared learning for the staff team, this has been shared via supervision and the Care Hub Quality Learning forum.
- ████████ consultant team, this has been shared via the lead ████████ patient meeting to support the importance of well-documented risk assessments.
- ████████ trust, this has been shared as trust wide learning for ████████ within the footprint to be aware of and learn from.
- Continued commitment to booking staff on the Clinical Risk Formulation ████████ STORM (suicide prevention skills) training; ward manager and service manager will monitor uptake and compliance with essential to role training.” Source location Response from Pennine Care 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 Face-to-face CMHT review was not necessarily required because the patient had not yet been allocated a care coordinator.
Verbatim wording from the response “Point 7
I am concerned that on the 9th March, Carl should have been seen face to face by the CMHT, in line with Trust Policy. Instead, he only received a telephone call from a duty worker who had never met him.” Source location Response from Pennine Care NHS Foundation Trust
Open published response
15 May 2023 Drew Howe · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to explore access to services from the patient’s perspective in investigations View source Lack of meaningful critical analysis in investigations View source Failure to consider the full extent of contacts with mental health services in investigations View source Failure to derive all available learning from deaths 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
Drew Howe · 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
Drew Howe was found dead on 19 October 2022 in a lorry on the A18 in Lincolnshire, having suspended himself by the neck with a ligature. He had experienced a deterioration in his mental health and was awaiting further assessment after being discharged without a diagnosis or treatment plan; concerns were raised that the Trust’s investigation did not fully examine his contacts with mental health services or derive all available learning.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explore access to services from the patient’s perspective in investigations
Wider context from the report “The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective . As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful critical analysis in investigations
Wider context from the report “The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events , and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the full extent of contacts with mental health services in investigations
Wider context from the report “The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services , lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to derive all available learning from deaths
Wider context from the report “The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death .
” 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 Ensure referral-related information, including assessments, is shared between services through team, supervision and operational meetings.
Verbatim wording from the response “• Teams to ensure that information, including assessment information is shared between services when referrals are made – to be discussed at team meetings, supervision, operational meetings. Trust to also explore if a digital prompt can be added to our Electronic Patient records to further support the inclusion of information when a referral is made.” Source location Response from Pennine Care 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 Explore adding a digital prompt to electronic patient records to support inclusion of referral information.
Verbatim wording from the response “• Teams to ensure that information, including assessment information is shared between services when referrals are made – to be discussed at team meetings, supervision, operational meetings. Trust to also explore if a digital prompt can be added to our Electronic Patient records to further support the inclusion of information when a referral is made.” Source location Response from Pennine Care 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 Share Trust-wide learning, including themes concerning military veterans’ experiences navigating mental health services.
Verbatim wording from the response “• Ensure trust wide learning including exploring themes around death by suicide of Military veterans in mental health services given concerns relating to the perspective of the client in navigating mental health services.” Source location Response from Pennine Care NHS Foundation Trust
Open published response
17 Aug 2022 Susan Mary Regan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to undertake the required enquiry with family members about possible psychiatric admission View source Failure to properly record care plans View source Failure to properly communicate care plans with family members View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Mary Regan · 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
Susan Mary Regan, aged 61, experienced deteriorating mental and physical health, including malnutrition, dehydration, disturbed behaviour and possible self-harm, before being admitted to hospital and later discharged with support. On 25 July 2020, she took her own life at home. The principal concerns were that the Home Treatment Team did not consult her sons about possible hospitalisation and did not properly record or communicate a care plan with them.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake the required enquiry with family members about possible psychiatric admission
Wider context from the report “1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit . Admission to also be considered if Ms Regan would continue to show non-compliance on her medications . Such an enquiry was not undertaken .
2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record care plans
Wider context from the report “1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non-compliance on her medications. Such an enquiry was not undertaken.
2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly communicate care plans with family members
Wider context from the report “1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non-compliance on her medications. Such an enquiry was not undertaken.
2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons .
” 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 Share serious-incident learning with the Home Treatment Team and raise the importance of timely, accurate care-plan documentation.
Verbatim wording from the response “The death of Ms Regan and subsequent internal serious incident investigation and learning has been shared with the HTT. The importance of timely and accurate documentation within patient case notes including agreed care plans has been raised within all disciplines within the team.” Source location Response from Pennine Care
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 Adjust multidisciplinary meetings to ensure regular consultant attendance and improve communication and care planning.
Verbatim wording from the response “It is also crucial to note that since the death of Ms Regan, the HTT now has a substantive Consultant Psychiatrist in place. This has brought a greater degree and consistency for both the team and patients using the service. The Multi-Disciplinary meetings (MDM’s) have been adjusted to ensure regular attendance of the consultant. This has allowed a better degree of communication and care planning with mutually agreed goals and actions.” Source location Response from Pennine Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a substantive Consultant Psychiatrist post within the Home Treatment Team.
Verbatim wording from the response “It is also crucial to note that since the death of Ms Regan, the HTT now has a substantive Consultant Psychiatrist in place. This has brought a greater degree and consistency for both the team and patients using the service. The Multi-Disciplinary meetings (MDM’s) have been adjusted to ensure regular attendance of the consultant. This has allowed a better degree of communication and care planning with mutually agreed goals and actions.” Source location Response from Pennine Care
Open published response
19 Nov 2021 Sarah McGarrigle · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks View source Failure to incorporate relevant collateral information and community history in mental disorder assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah McGarrigle · 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
Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct capacity assessments using communicated information and a longitudinal assessment of community self-neglect risks
Wider context from the report “(2) That the Consultant Psychiatrists who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased’s capacity was raised in the context of her withdrawal from alcohol . Consideration of the information that had been communicated to Aspen Ward (which included the specific limb of the capacity test that was in doubt) and a more longitudinal approach to the assessment would have shown that the concern related to the far more complex picture that the Deceased presented in the community and management of risks associated with self-neglect . This was not addressed by those responsible for assessing the Deceased on Aspen Ward .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate relevant collateral information and community history in mental disorder assessments
Wider context from the report “(1) That the clinicians on Aspen Ward did not consider relevant information provided to the ward by the allocated social worker and the AMHP in the assessment of the Deceased’s mental disorder . The was an over-reliance on Sarah’s presentation on the ward and insufficient consideration given to the concerns that had been raised by community agencies, her psychiatric history and behaviours in the community setting .
” 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 Design a Mental Capacity Act audit.
Verbatim wording from the response “• The PCFT safeguarding team are designing a Mental Capacity Act audit.” Source location Response from NHS Pennine Care 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 Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
Verbatim wording from the response “• The concerns identified during the inquest have been reviewed by Professor Nihal Fernando, PCFT’s Executive Medical Director. Professor Fernando will share a copy of PCFT’s Regulation 28 response with the Aspen ward consultant Psychiatrists Responsible Officer, in his new Trust.” Source location Response from NHS Pennine Care 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 process for arranging and facilitating discharge-planning and ward-round meetings.
Verbatim wording from the response “████████o reduce the likelihood of similar incidents occurring in the future, the PCFT Oldham Triumvirate Leadership Team have held several meetings to renew the discharge process on its inpatient adult acute mental health wards. A number of ████████tions to improve the quality of discharges have been taken, which include:” Source location Response from NHS Pennine Care 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 PARIS across inpatient mental health wards, including a mental-capacity assessment documentation template.
Verbatim wording from the response “• PCFT has successfully implemented PARIS in all its inpatient mental health wards. This electronic patient record system includes a mental capacity assessment template that clinicians can use to document their assessments.” Source location Response from NHS Pennine Care 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 Commission Mental Capacity Act training for all clinicians.
Verbatim wording from the response “There is evidence the Aspen Ward MDT considered Sarah’s mental capacity to make decisions about drinking alcohol, the risks associated with, however the Aspen Ward MDT did not complete and document a formal mental capacity assessment. This area of practice that required improvement had been identified in a PCFT investigation completed after Sarah’s death (but before Sarah’s inquest). Several actions have been taken since the time of Sarah’s admission to Aspen Ward which improve how inpatient wards consider and apply the mental capacity act in practice:” Source location Response from NHS Pennine Care 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 Escalate the need for additional longitudinal mental-capacity education to the Safeguarding Team and Mental Health Law and Scrutiny Group.
Verbatim wording from the response “• The learning from Sarah s Inquest regarding a potential missed opportunity for clinicians to consider a more longitudinal approach to assessing mental capacity assessments has been shared with senior Consultant Psychiatrists in Oldham. There was some agreement that additional education in this area could be beneficial. This will be escalated to the PCFT Safeguarding Team and the Mental Health Law and Scrutiny Group.” Source location Response from NHS Pennine Care 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 Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Verbatim wording from the response “• PCFT’s Head of Safeguarding and the Named Professional for Safeguarding Adults will make a recommendation to the Oldham Safeguarding Adult Partnership Board that a multi-agency protocol be developed. The recommended protocol would outline the roles and responsibilities of each agency when assessing mental capacity for complex patients with a mixture of health and social care needs. The guidance would also outline how multi-agency partners can request specialist mental health input for a mental capacity assessment.” Source location Response from NHS Pennine Care 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 Deliver mental-capacity lunch-and-learn sessions in Oldham.
Verbatim wording from the response “████████commissioned Mental Capacity Act training for all clinicians.
████████arding team have delivered lunch and learn sessions on mental capacity in Oldham.” Source location Response from NHS Pennine Care 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 Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
Verbatim wording from the response “• Oldham's mental health services now have a route to refer patients to the Oldham multi-agency Adults with Multiple Complex Needs Meeting. This ████████to support professionals to work with complex patients who present with high levels of risk but are assessed as having the mental capacity to make unwise decisions or do not engage with their care and treatment.” Source location Response from NHS Pennine Care 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 Share inquest learning about longitudinal mental-capacity assessment with senior Oldham consultant psychiatrists.
Verbatim wording from the response “• The learning from Sarah s Inquest regarding a potential missed opportunity for clinicians to consider a more longitudinal approach to assessing mental capacity assessments has been shared with senior Consultant Psychiatrists in Oldham. There was some agreement that additional education in this area could be beneficial. This will be escalated to the PCFT Safeguarding Team and the Mental Health Law and Scrutiny Group.” Source location Response from NHS Pennine Care 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 an inpatient–community interface meeting to improve discharge-planning information sharing and communication.
Verbatim wording from the response “████████o reduce the likelihood of similar incidents occurring in the future, the PCFT Oldham Triumvirate Leadership Team have held several meetings to renew the discharge process on its inpatient adult acute mental health wards. A number of ████████tions to improve the quality of discharges have been taken, which include:” Source location Response from NHS Pennine Care 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 The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
Verbatim wording from the response “physical symptoms of withdrawal. On admission to Aspen Ward, she was not experiencing any alcohol-related behavioural issues. It is widely accepted that alcohol use can cause or increase symptoms of behavioural and/or mental illness. For some patients, when they stop alcohol, their symptoms can significantly improve or stop all together. Sarah’s overall presentation from the time she was assessed and detained under the MHA in the Royal Oldham Acute Hospital, compared to while an inpatient on Aspen was significantly better. Sarah appeared to improve in the time between being detained under Section 2 and being transferred to Aspen Ward (which was a period of several days). Sarah had been safely using leave off the medical wards for a cigarette break. While on Aspen Ward, she also used leave off the ward for cigarettes.” Source location Response from NHS Pennine Care Foundation Trust
Open published response
28 May 2021 Angela Marie FROST · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of a formal second-opinion process for Consultant Psychiatrists View source Lack of in-patient Consultant understanding of confidentiality and permissible communication with family members View source Lack of a formal second-opinion process for health care professionals or family members View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Marie FROST · 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
Angela Marie FROST was admitted to hospital after a mixed overdose and later went missing with the intention of starving herself to death. She was found at home on 24 August 2020 after taking an intentional overdose of her partner’s old medication; the inquest recorded the medical cause of death as amitriptyline overdose and concluded suicide whilst the balance of her mind was disturbed. The principal concerns included the absence of formal processes for seeking second opinions and inadequate understanding of confidentiality and permissible communication with family members.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal second-opinion process for Consultant Psychiatrists
Wider context from the report “(1) There is no formal guidance or process in place at the Trust for Consultant Psychiatrists to seek a second opinion in relation to diagnosis, treatment plans or whether a patient meets the criteria for detention under the Mental Health Act . The evidence was that whilst there is nothing to prohibit a Consultant requesting a second opinion, it rarely happens in practice .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of in-patient Consultant understanding of confidentiality and permissible communication with family members
Wider context from the report “(3) The court heard evidence that there is a lack of understanding on the part of in-patient Consultants as to rules around confidentiality and the nature/extent of permissible communication with family members ie: the difference between receiving information which might inform diagnosis, treatment and risk planning and discussions which involve sharing confidential health 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal second-opinion process for health care professionals or family members
Wider context from the report “(2) There is no formal guidance or process in place at the Trust for health care professionals or family members to seek a second opinion in relation to the matters set out above.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit the drafted second-opinion process to the Trust Quality Group for scrutiny and sign-off.
Verbatim wording from the response “- A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion.
- The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services.” Source location 2021-0183-Response-from-Pennine-Care-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 Implement the second-opinion process across all Trust services.
Verbatim wording from the response “- A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion.
- The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services.” Source location 2021-0183-Response-from-Pennine-Care-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 Write a formal process enabling consultants, healthcare professionals, patients, families and carers to request second opinions.
Verbatim wording from the response “Since Ms Frost's untimely death, the Triumvirate Leadership Team for Oldham's Mental Health Services has reviewed the Trusts internal processes to request second opinions. Below is a summary of the work that has been done so far:” Source location 2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
Open published response
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 22 Limited police recognition and use of Claire's Law in domestic abuse cases View source Unqualified staff making key MARAT decisions View source Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators View source Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators View source Poor information sharing and joint risk recognition across statutory agencies View source Limited police training and capability to identify coercive and controlling behaviour View source Insufficient health visitor capacity for safeguarding and interagency work View source Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible View source Reduced specialist support and oversight for low and medium risk domestic abuse cases View source Failure to share complete relevant information between police and CPS View source Failure of CPS decision makers to follow guidance and document prosecution assessments View source Limited health visitor understanding of coercive and controlling behaviour View source Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs View source Failure to share perpetrator risk information with alleged victims View source Failure to place domestic abuse suspects on protective bail conditions during further investigation View source Failure to provide safe opportunities for domestic abuse disclosure View source Failure to pursue further enquiries supporting victimless domestic abuse prosecutions View source Failure to routinely document police and CPS case discussions View source Failure to use the MARAC framework when appropriate View source Limited police training in domestic abuse risk evaluation and scoring View source Insufficient resourcing of the MARAT frontline service View source Failure to conduct required health visiting conversations face to face View source See 19 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
Alfie Gildea · 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
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unqualified staff making key MARAT decisions
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions . Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different . It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor . As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator . Opportunities to use the MARAC framework were not taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements . As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems . Officers giving evidence did not understand how such information could be accessed or recorded .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share complete relevant information between police and CPS
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed . The file that was submitted omitted key information available to GMP that would have been important to the decision maker . The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim . The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed . There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share perpetrator risk information with alleged victims
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required . Instead they were placed under investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe opportunities for domestic abuse disclosure
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document police and CPS case discussions
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the MARAC framework when appropriate
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the MARAT frontline service
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced . This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required health visiting conversations face to face
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face . The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report
23 Oct 2020 Sean Robert Steven Owen · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of quality assurance of discharge summary letters View source Discharge summary letters failing to communicate significant clinical risks and incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sean Robert Steven Owen · 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
Sean Robert Steven Owen had a history of treatment-resistant paranoid schizophrenia and was recognised as being at significant risk if non-compliant with medication. After medication monitoring arrangements broke down, he self-inflicted a penetrating neck injury on 3 June 2019 and died on 14 June 2019 from his injuries and a chest infection. The report raised concerns that his discharge letter omitted significant information about overdoses, suicidal thoughts and the risks associated with medication non-compliance, and that there was no quality assurance system for such letters.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of quality assurance of discharge summary letters
Wider context from the report “I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care . The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician . It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge summary letters failing to communicate significant clinical risks and incidents
Wider context from the report “I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission ; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance .
” 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 Provide all new medical trainees with training on admission and discharge summary standards and processes.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-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 Check and discuss new trainees’ admission and discharge summaries during their first month, with senior-doctor review before discharge.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-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 Issue new trainees laptops and require admission and discharge summaries to be maintained as live documents throughout patients’ admissions.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-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 Incorporate documentation review into trainees’ weekly supervision.
Verbatim wording from the response “The Clinical Director for the Borough has established process that ensures:” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-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 the revised admission and discharge summary process.
Verbatim wording from the response “The revised process will be subject to an audit.” Source location 2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf
Open published response
23 Apr 2020 Gordon Fenton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of a formalised joint process for reviewing treatment plans and determining optimum medical and psychiatric care View source Lack of effective coordination of shared psychiatric and acute medical care View source Failure to reliably and consistently share medical records and information between Trusts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gordon Fenton · 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
Gordon Fenton, a 70-year-old man detained under the Mental Health Act, developed a urinary tract infection and related complications during periods of care between psychiatric and medical services, and died in hospital on 29 June 2019 after a seizure and cardiac arrest. The principal concerns were inadequate information sharing and the lack of a formal joint decision-making process between the two NHS Trusts, with the inquest finding that this prolonged and contributed to ineffective management of his infection.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formalised joint process for reviewing treatment plans and determining optimum medical and psychiatric care
Wider context from the report “3. There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient’s 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective coordination of shared psychiatric and acute medical care
Wider context from the report “1. The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably and consistently share medical records and information between Trusts
Wider context from the report “2. There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts .
” 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 working parameters and pilot Digital Health Team support for physical health needs on Summers and Hague wards.
Verbatim wording from the response “This SOP will apply to all patients within PCFT’s Tameside older peoples’ mental health in-patient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers and Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot, in the first instance for eight weeks, which will then be reviewed by both organisations to establish a more formal offer and outcomes. It is hoped that, if this procedure is successful, that similar processes will be developed for all of our patients requiring shared input.” Source location 2020-0102-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Deliver and document self-directed training for staff covered by the approved joint SOP.
Verbatim wording from the response “Please note that this SOP remains in its implementation stages as both Trusts are working to align their own pathways with the new arrangement. It is planned that his will go live at the end of August 2020. Once the new SOP is approved by both Trusts, self-directed training will be carried out by all staff to which the SOP is relevant and this training will be documented in their training record.” Source location 2020-0102-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and apply structured pathways for acute deterioration, chronic-condition advice, information gathering, and transfers of care.
Verbatim wording from the response “A number of pathways have also been created with regards to mental health in-patient transfers of care and return in-patient transfers of care. In terms of transfers of care, the process will be split into three categories;” Source location 2020-0102-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Implement the joint Standard Operating Procedure for shared physical and mental healthcare of older inpatients requiring medical input.
Verbatim wording from the response “As part of our investigation into your concerns, extensive discussions have taken place between Tameside’s Associate Director and Mental Health Quality Lead at PCFT and the Head of Assurance and Governance and Lead Nurse for Mental Health and Learning Disabilities at TGICFT in relation to ongoing improvements in shared service, specifically in relation to creating a formal standard operating ████████ and enhancing services offered by TGICFT.” Source location 2020-0102-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Open published response
22 Apr 2020 ALLAN WILLIAM CUNLIFFE · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Inaccurate or lacking recording of clinical observations and NEWS scores View source Confusion regarding oxygen administration View source Inadequate action on clinical observations and NEWS scores View source Poor physical care of vulnerable patients on Summers Ward View source Poor communication between doctors and nurses View source Lack of awareness of mandatory training requirements among nurses View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
ALLAN WILLIAM CUNLIFFE · 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
Allan Cunliffe, who had bowel problems and mental health issues, became ill on Summers Ward on 17 July 2018 and died in A&E on 18 July 2018 after deterioration associated with a perforated bowel and sepsis. The substantive concerns included poor communication, inadequate recording and calculation of NEWS scores, failures to follow observation protocols, and confusion about oxygen administration, with the jury stating that insufficient record keeping and communication probably led to an avoidable death.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate or lacking recording of clinical observations and NEWS scores
Wider context from the report “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking . There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion regarding oxygen administration
Wider context from the report “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen , with at least one nurse being apparently unaware of the mandatory training.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate action on clinical observations and NEWS scores
Wider context from the report “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking . There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor physical care of vulnerable patients on Summers Ward
Wider context from the report “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor . Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication between doctors and nurses
Wider context from the report “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of mandatory training requirements among nurses
Wider context from the report “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training .
” 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 Reinforce accurate NEWS2 completion and documentation through staff communication and regular supervision.
Verbatim wording from the response “Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A ████████ o all staff members reiterating the importance of ensuring that [redacted text]culated accurately and signed appropriately. All refusals of [redacted text]tion of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance ████████ standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:” Source location 2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Provide rolling NEWS2 training covering accurate scoring, escalation, clinical deterioration and sepsis recognition.
Verbatim wording from the response “Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A ████████ o all staff members reiterating the importance of ensuring that [redacted text]culated accurately and signed appropriately. All refusals of [redacted text]tion of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance ████████ standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:” Source location 2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Progress an agreement with the Digital Health Team to provide specialist physical-health advice to inpatient clinical teams.
Verbatim wording from the response “In addition to the above a series of meetings have taken place this year between the Older People’s Mental Health Service and the Digital Health Team which is part of Tameside Integrated Care Foundation Trust (ICFT) to explore ways of providing a holistic and consistent approach to accessing timely specialist advice in relation to the physical health needs of older people on the inpatient mental health unit at Tameside Hospital who often have complex co-morbid physical and mental health needs.” Source location 2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Provide Acute Illness Management training for registered and unregistered nursing staff on assessing and responding to deteriorating patients, including oxygen therapy.
Verbatim wording from the response “More recently Pennine Care now also provides Acute Illness Management training for both registered and unregistered nursing staff. A workshop covering the systematic approach to assessing a deteriorating patient is delivered. During this airways and breathing are discussed and includes how to assess, and take action (inclusive of oxygen), in the event of an emergency. A demonstration/simulation is also delivered. The course details why a person needs oxygen to survive and the consequences of our body not receiving enough whilst also detailing normal and abnormal signs relating to the airway and breathing.” Source location 2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Circulate a seven-minute briefing to raise awareness of training content and staff compliance responsibilities.
Verbatim wording from the response “A 7 minute briefing will be circulated to raise awareness of the content of this training and staff’s responsibility of maintaining compliance with such.” Source location 2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_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 Audit five randomly selected NEWS2 charts monthly to oversee compliance with documentation standards.
Verbatim wording from the response “Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A ████████ o all staff members reiterating the importance of ensuring that [redacted text]culated accurately and signed appropriately. All refusals of [redacted text]tion of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance ████████ standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:” Source location 2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Open published response
20 Jan 2020 Samantha Savage-Greene · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of provision of supervision and monitoring for patients falling between RAID and HBTT admission protocols 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
Samantha Savage-Greene · 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 23 May 2018, Samantha Savage-Greene jumped from a bridge over the M67 motorway and sustained fatal injuries. The principal concern was difficulty obtaining monitoring from the Home Based Treatment Team, with an apparent gap between the RAID and Home Based Treatment Team protocols for patients who were not admitted.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of provision of supervision and monitoring for patients falling between RAID and HBTT admission protocols
Wider context from the report “The MATTER OF CONCERN is that despite the concerns of the RAID practitioner that the HBTT refused to accept Samantha, as she did not fit the protocol for acceptance, on the first two requests. The HBTT was the only means by which Samantha could be monitored other than an admission and satisfy the RAID practitioners concerns. Samantha was accepted by the HBTT on the third time of asking. This appears to be because the person receiving the request was prepared to see Samantha, a person rather than restricted by protocol and by the fact that the RAID practitioner was so concerned about Samantha that she was going to review Samantha within the RAID processes, which was not part of its remit. Without monitoring it would not have been possible to prescribe olanzapine.
There is clearly a lacuna in the provision of supervision and monitoring of patients who are not deemed admissible, voluntarily or by section between the RAID and HBTT services. The RAID practitioner should not have experienced such difficulty in obtaining monitoring for Samantha, a patient who appeared to fall between the protocols of two services.
” Open source report
23 Dec 2019 Kieran Luke Hubbard · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure to update the responsible psychiatrist so that the position can be reconsidered View source Abandonment of inpatient bed searches without establishing the information required to consider the request View source Failure to urgently discover and record information required for inpatient bed provision View source Failures in the post-death investigation process View source Unavailability of quick and reliable inter-trust communication for urgent bed placement View source Lack of guidance for advising patients in mental health crisis to stop driving or using machinery View source Failure to expedite the search for and securing of an appropriate inpatient bed 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
Kieran Luke Hubbard · 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
Kieran Luke Hubbard, who had a history of depressive disorder and recurrent suicidal thoughts, was found dead on 8 February 2019 after hanging himself at a building site. The principal concerns were failures to expedite and properly coordinate an inpatient bed, failures to communicate and escalate the decision to abandon the bed search, inadequate guidance about driving during a mental health crisis, and shortcomings in the post-death investigation.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update the responsible psychiatrist so that the position can be reconsidered
Wider context from the report “5 3 The decision to abandon the search for a bed was taken by healthcare professionals without knowledge of exactly what information, if any, PCFT required to consider the request and without updating the psychiatrist in charge of the deceased care in order for them to consider and reassess the position This appears to be a wholly inappropriate and unsatisfactory position
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Abandonment of inpatient bed searches without establishing the information required to consider the request
Wider context from the report “5 3 The decision to abandon the search for a bed was taken by healthcare professionals without knowledge of exactly what information, if any, PCFT required to consider the request and without updating the psychiatrist in charge of the deceased care in order for them to consider and reassess the position This appears to be a wholly inappropriate and unsatisfactory position
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to urgently discover and record information required for inpatient bed provision
Wider context from the report “5 2 There was a failure by GMMH to fully and properly discover and record urgently or in a timely manner exactly what information was apparently required by PCFT in order to facilitate the provision of a bed. Consequently, there was no opportunity to provide that information and secure in bed which may been available when the deceased had agreed to become an inpatient He was therefore out of hospital and not in a safe and supervised location when he killed himself
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failures in the post-death investigation process
Wider context from the report “5 6 There were failures in the post death investigation process which may result in the true circumstances not being identified and steps taken to prevent continuation or
recurrence of circumstances which may cause or contribute to a future death
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of quick and reliable inter-trust communication for urgent bed placement
Wider context from the report “5.4 If it is not possible to change or alter the "out of area" catchment area for mental health trusts then GMMH and PCFT should ensure that there are quick and reliable methods of communication between to secure a bed as soon as possible If either trust requires further information this too is communicated quickly, recorded and obtained if possible and the trust seeking a placement can make alternative arrangements urgently.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for advising patients in mental health crisis to stop driving or using machinery
Wider context from the report “5 5 There did not appear to be any specific guidance , policy or protocol to assist healthcare staff in advising patients to stop driving motor vehicles or using machinery whilst in a mental health crisis ( in accordance with any DVLA guidance that exists ) which may put themselves or others at risk of death or serious harm
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to expedite the search for and securing of an appropriate inpatient bed
Wider context from the report “5 1 The failure by GMMH to expedite the search for and securing an inpatient bed which a consultant psychiatrist has clinically decided was appropriate to provide a safe and supervised environment for ongoing assessment and treatment for a patient with a serious diagnosed mental disorder who had made a very recent attempt to kill themselves This will also require liaison with PCFT because both trusts will come into contact with one another quite regularly
” Open source report
13 Dec 2019 Steven Keith Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to engage families and work with them to support people in the community View source Lack of a clear CMHT policy for effectively engaging families View source Failure to provide regular CMHT contact in the community View source Failure to escalate or discuss very limited post-discharge contact View source Failure to make a follow-up appointment at discharge View source Failure to allocate people moving between borough teams to a community psychiatrist View source See 3 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
Steven Keith Marsland · 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
Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage families and work with them to support people in the community
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT;
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear CMHT policy for effectively engaging families
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT ;
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular CMHT contact in the community
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate or discuss very limited post-discharge contact
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make a follow-up appointment at discharge
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made ;
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate people moving between borough teams to a community psychiatrist
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made;
” Open source report
6 Nov 2019 Hazel Maureen Lewis · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Failure to correctly identify the statutory advocate’s role View source Inadequate Mental Capacity Act training for decisions concerning life-sustaining treatment View source Lack of clarity about the referral requirements for IMCA involvement View source Failure to identify and consult relevant consultees in Mental Capacity Act decisions View source Failure to correctly apply Mental Capacity Act capacity requirements to decisions about investigations View source Failure to follow the required order of Mental Capacity Act best-interest decision-making steps View source Failure to formally instruct an Independent Mental Capacity Advocate when required View source Failure to explore and advise on available support options for engagement with medical investigations or care View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Hazel Maureen 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
Hazel Maureen Lewis died in hospital on 28 November 2018 after an unwitnessed fall caused a hip fracture; the medical cause of death was metastatic breast cancer, with the fracture contributing. Concerns were raised about the best-interest decision-making process, including inadequate consultation, failure to formally instruct an IMCA, insufficient exploration of support to help her engage with investigations, and uncertainty about the advocate’s role.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly identify the statutory advocate’s role
Wider context from the report “The statutory advocate involved in the Deceased’s care was acting as a Care Act Advocate rather than an IMCA . I heard evidence that in order for the advocate to act as an IMCA, a separate referral to Advocacy Together would be required. Both the GP and social worker had understood that the advocate involved in the Deceased’s case was acting as an IMCA . There is a need for greater clarity as to which role an advocate is acting so that all agencies involved in the care of individuals lacking capacity can ensure that the requirements of the MCA are complied with.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate Mental Capacity Act training for decisions concerning life-sustaining treatment
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment .
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the referral requirements for IMCA involvement
Wider context from the report “The statutory advocate involved in the Deceased’s care was acting as a Care Act Advocate rather than an IMCA. I heard evidence that in order for the advocate to act as an IMCA, a separate referral to Advocacy Together would be required . Both the GP and social worker had understood that the advocate involved in the Deceased’s case was acting as an IMCA. There is a need for greater clarity as to which role an advocate is acting so that all agencies involved in the care of individuals lacking capacity can ensure that the requirements of the MCA are complied with .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and consult relevant consultees in Mental Capacity Act decisions
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment.
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP . The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted . An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly apply Mental Capacity Act capacity requirements to decisions about investigations
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment.
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations . A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the required order of Mental Capacity Act best-interest decision-making steps
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment.
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA , the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care . Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally instruct an Independent Mental Capacity Advocate when required
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment.
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed . There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care. The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explore and advise on available support options for engagement with medical investigations or care
Wider context from the report “Whilst evidence was given that all witnesses had undergone mandatory Mental Capacity Act 2005 (MCA) training, the Court was left with some concerns about the adequacy of that training as it relates to decisions concerning life-sustaining treatment.
It would appear that those involved in the Deceased’s care did not fully understand the order in which steps are to be taken under the MCA, the nature of consultation and the role of consultees, when an IMCA is to be instructed and the need to explore all available options before a best interest decision is reached.
The best interest decision not to proceed with investigations in this case was taken prior to consultation with those involved in the Deceased’s care. Neither the social worker or community learning disability nurse appreciated that they were being consulted when spoken to by the GP. The carers who provided daily care to the Deceased and who had been able to foster her engagement with social care were not consulted. An IMCA was not formally instructed. There was no exploration of or advice given in relation to the options available to support the Deceased in engaging with medical investigations or medical care such as desensitisation or 1:1 care . The community learning disability nurse’s understanding was that the Deceased had the capacity to decline investigations. A best interest meeting was not convened and whilst this was not mandatory under these circumstances, it would have afforded an opportunity to ensure that agencies applied their minds to the possibility that the Deceased may engage with investigations if additional support was offered. It would also have facilitated more effective communication between the agencies and on-going management of the consequences of the best interest decision.
” Open source report
24 Sep 2019 Muhammed Saif Abdul Haleem · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to maintain current information for immediate guidance to paramedics View source Lack of communication of existing DNA-CPRs or Advance Care Plans between community paediatric teams and emergency services View source Failure to ensure immediate guidance is known to and supported by clinicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Muhammed Saif Abdul Haleem · 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
Muhammed Saif Abdul Haleem was 13 years old and had a severe, life-limiting neurological condition. He became unresponsive at home on 8 December 2018, was found in asystole, and died after resuscitation efforts were terminated; the principal concern was that an outdated DNA-CPR document had remained on the emergency service system for seven years without the knowledge or support of the clinicians involved in his care.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain current information for immediate guidance to paramedics
Wider context from the report “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making
The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication of existing DNA-CPRs or Advance Care Plans between community paediatric teams and emergency services
Wider context from the report “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making
The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediate guidance is known to and supported by clinicians
Wider context from the report “That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved in this child’s care at the time of his death. Whilst I accept the evidence that paramedics will make a clinical decision based on the patient’s presentation at the time, the fact that they sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making
The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review archived records for children with palliative care needs to identify advance care plans predating the electronic system and include them in alerts.
Verbatim wording from the response “I can confirm that alerts have now been placed on the NWAS system for all children who have current advance care plans (ACP) - these alerts will be reviewed if any changes are made or as a minimum once per year when the ACP is reviewed. In addition, we will review archived patient notes/records for any children with palliative care needs known to the Children’s Community Nursing Team (CCNT) on 15/11/19 to ensure that any ACP’s that may have commenced before the electronic system was set up are included.” Source location 2019-0316-Response-by-Pennine-Care-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 Place alerts on the NWAS system for children with current advance care plans and review them when changed or at least annually.
Verbatim wording from the response “I can confirm that alerts have now been placed on the NWAS system for all children who have current advance care plans (ACP) - these alerts will be reviewed if any changes are made or as a minimum once per year when the ACP is reviewed. In addition, we will review archived patient notes/records for any children with palliative care needs known to the Children’s Community Nursing Team (CCNT) on 15/11/19 to ensure that any ACP’s that may have commenced before the electronic system was set up are included.” Source location 2019-0316-Response-by-Pennine-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate current advance care plan information and provide child lists to relevant hospital children’s services to support replication of alert systems.
Verbatim wording from the response “We have also communicated with the Lead Nurse at the Royal Oldham Hospital Children’s A&E department and forwarded a list of the children known to CCNT who have ACP’s to enable them to set up their own alert system. We have also communicated with the Oldham Children’s unit and O&A to replicate the same system.” Source location 2019-0316-Response-by-Pennine-Care-NHS-Trust
Open published response
19 Sep 2019 Mr Bromley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Unreliable rota-based access to psychiatric advice for the Home Treatment Team View source Failure to progress and communicate recruitment arrangements for the dedicated consultant psychiatrist post View source Lack of a dedicated consultant psychiatrist allocated to the Home Treatment Team 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
Mr Bromley · 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 Bromley was receiving support from the Home Treatment Team after declining an informal hospital admission. He was found dead on 18 February 2019 at his gym, having suspended himself by the neck with a ligature; the inquest recorded a conclusion of suicide. The concerns related to the Home Treatment Team’s lack of a dedicated Consultant Psychiatrist, uncertainty about recruitment to such a post, and the patchy operation of interim psychiatric access arrangements.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliable rota-based access to psychiatric advice for the Home Treatment Team
Wider context from the report “1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service;
2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled;
3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy , with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload .
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to progress and communicate recruitment arrangements for the dedicated consultant psychiatrist post
Wider context from the report “1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service;
2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train , let alone the timescales within which it might reasonably be anticipated the post will be filled ;
3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a dedicated consultant psychiatrist allocated to the Home Treatment Team
Wider context from the report “1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service ;
2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled;
3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload.
” Open source report
4 Jul 2019 Miriam Tighe · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to discontinue promazine after specialist advice to stop it View source Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions 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
Miriam Tighe · 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
Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discontinue promazine after specialist advice to stop it
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016 . On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home . In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016, which led to unsafe prescribing of sedatives and antipsychotic medication.
” 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016. On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home. In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016 , which led to unsafe prescribing of sedatives and antipsychotic medication .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations