14 Feb 2019 John Andrew Mellor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to establish shared care arrangements or identify an organisation for blood sampling for drug monitoring View source Failure to ensure required blood tests for individuals under specialist secondary care for renal failure View source Failure to communicate referral responses, referral updates and community test requests directly to primary care 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
John Andrew Mellor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.
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 establish shared care arrangements or identify an organisation for blood sampling for drug monitoring
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” Open source report × Source evidence
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 required blood tests for individuals under specialist secondary care for renal failure
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure . Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility .
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” Open source report × Source evidence
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 communicate referral responses, referral updates and community test requests directly to primary care
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly , with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider .
” Open source report
28 Jan 2019 Mr Crutchley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Significant waits for talking therapies View source Lack of specialist drug and alcohol workers within the Early Intervention Team View source Dependence of service-user interaction with specialist drug and alcohol professionals on self-referral 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 Crutchley · 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 Crutchley was found dead at the home he shared with his parents, and the post-mortem examination concluded that he died from the combined toxic effects of cocaine and alprazolam. Concerns were raised that the Early Intervention Team lacked specialist drug and alcohol workers and that service users could face significant waits for talking therapies.
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 Significant waits for talking therapies
Wider context from the report “Whilst the witness who gave evidence on behalf of the trust was unable to provide details of current waiting times, it is a matter of additional concern that at times significant wait can be encountered by service-users referred for talking therapies . The evidence before the court suggested such delays were often associated with difficulties recruiting and retaining appropriately qualified therapists.
” Open source report × Source evidence
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 specialist drug and alcohol workers within the Early Intervention Team
Wider context from the report “It is a matter of concern that the Early Intervention Team does not include specialist drug and alcohol workers amongst its number . Such professionals work for external providers and interaction with service users appear to be dependent on self-referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Dependence of service-user interaction with specialist drug and alcohol professionals on self-referral
Wider context from the report “It is a matter of concern that the Early Intervention Team does not include specialist drug and alcohol workers amongst its number. Such professionals work for external providers and interaction with service users appear to be dependent on self-referral .
” Open source report
28 Dec 2018 Mr Gregory Rekowski · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to escalate welfare incidents to the on-call senior manager View source Lack of clarity about police powers and role for Section 136 from-home cases View source Lack of ward staff awareness of telephone restrictions affecting 111 calls View source Unavailability of an out-of-hours mental-health community response service for face-to-face assessment View source Unclear and delayed police-to-ambulance referral process for welfare concerns View source Delays in accepting and passing on welfare concerns because of confidentiality uncertainty View source Conflicting advice about which agency to contact for welfare concerns View source Failure to identify and disclose material call-handling information during investigation View source Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life View source Delays and failures in handling welfare concerns within acute inpatient psychiatric wards View source Incorrect completion of triage-system questions View source Insufficient investigation of deaths by NWAS View source Failure to provide face-to-face welfare assessment View source Mental-health telephone triage by staff with insufficient mental-health training 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 Gregory Rekowski · 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 Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate welfare incidents to the on-call senior manager
Wider context from the report “No-one considered, at any stage the escalation of this incident to the on-call Senior manager when they were having difficulties contacting the emergency services or when GMP had provided the advice to contact NWAS.
” Open source report × Source evidence
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 police powers and role for Section 136 from-home cases
Wider context from the report “There is a lack of acknowledgment of the role of the police when dealing with people who are taken on a Section 136 from their own home. The Court did not explore the numbers of Section 136 patients who are taken to a place of safety from their home address. The Court heard how Mr Rekowski had been taken from his own home on the 17th September. Other agencies are clearly familiar with this process and how GM policiante this was also used as an explanation as to why GMP may have been restricted in what they could do on the 27th and 28th October ie, “...there is nothing we can do if we attend at his home own. We have no powers.” There appears to be a significant difference between the legal position and the practical reality of how police deal with such matters if they are called to a home address. This inconsistency is causing confusion amongst 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 Lack of ward staff awareness of telephone restrictions affecting 111 calls
Wider context from the report “Non of the ward staff were aware of the restrictions on the ward telephones which prohibit 111 calls from being, this meant time was spent trying to make such calls .
” Open source report × Source evidence
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 an out-of-hours mental-health community response service for face-to-face assessment
Wider context from the report “The Court heard evidence there is no Mental Health Community Response team available to deal with mental health issues out of hours . The only out of hours service is in A&E which would necessitate someone attending there. Evidence was given as to the substantial increase in such issues being reported to GMP. The Court heard how there is now a mental health professional within the GMP control room to assist with the calls received. However the main issues are in attending to conduct face to face assessments . The police are the service who have a power to enter property, unlike other services. Therefore whilst they may not be best placed in respect of the assessment they are often called. Given the issue in respect of resources laid throughout this Inquest the Court would question the lack of this Mental Health provision .
” Open source report × Source evidence
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 Unclear and delayed police-to-ambulance referral process for welfare concerns
Wider context from the report “In this case GMP did not call NWAS and asked the nurses to contact NWAS . The Court heard evidence from the Deputy Sector manager for NWAS as to how GMP will contact them to attend concerns for welfare. This was not a process PCT staff were familiar with . This also led to a delay in the call being 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 Delays in accepting and passing on welfare concerns because of confidentiality uncertainty
Wider context from the report “The Court heard the calls between NK and NWAS. Advice was provided to NK that a concern for welfare could not be taken by them due to a potential “breach of confidentiality” . This led to a further delay in this concern for welfare call being passed to NWAS.
” Open source report × Source evidence
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 Conflicting advice about which agency to contact for welfare concerns
Wider context from the report “Evidence was heard from the Inpatient Services Manager of PCT of their understanding, that the Police are the organisation to call in relation to concerns for welfare (regarding risk to life). The Court heard PCT are still advised the police are the contact . In addition this the advice within the acute trusts.
” Open source report × Source evidence
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 disclose material call-handling information during investigation
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case. It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care.
” Open source report × Source evidence
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 Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life
Wider context from the report “It was clear to the Court from all Senior Managers that there was a distinct lack of understanding across all three agencies of each agencies roles/responsibilities, systems of working and current practices in relation to concerns for welfare involving risk to life (not immediate to someone in the process of harming themselves). The evidence to the Court was of a confused picture across Greater Manchester with no clear guidance as to how to deal with such matters. Moreover it was apparent there is no documented GM wide process to allow staff on the ground clear information as to how to deal with such matters.
” Open source report × Source evidence
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 Delays and failures in handling welfare concerns within acute inpatient psychiatric wards
Wider context from the report “The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this , given they were working on an acute in-patient psychiatric ward. It was unclear why the clinical lead did not deal with this matter as she was the person to whom the information had initially 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 Incorrect completion of triage-system questions
Wider context from the report “The Court heard how the call was graded as a Grade 3 however when taken through the evidence in Court several questions on the triage system had been incorrectly completed .
” Open source report × Source evidence
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 investigation of deaths by NWAS
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case . It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care.
” Open source report × Source evidence
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 welfare assessment
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted . Moreover the telephone triage call was conducted by a RGN who had limited mental health 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 Mental-health telephone triage by staff with insufficient mental-health training
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted. Moreover the telephone triage call was conducted by a RGN who had limited mental health 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 Issue a memo to all staff increasing awareness of the requirement to seek support from on-call managers.
Verbatim wording from the response “PCFT have issued the memo (attached) to all staff to ensure that there is greater awareness of the requirement to seek support from the On-Call managers.” Source location 2018-0411-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 Increase ward staffing through the Safer Staffing initiative to release more time for care.
Verbatim wording from the response “Information received from the Clinical Lead, who works across both wards on the unit indicates that she passed the request to the nurse in charge of the ward where Mr Rewkowski had recently been cared for as an inpatient. It is recognised that the response of inpatient staff on this occasion was delayed due to the competing demands of dealing with the patients they were directly responsible for on the unit, and this information relating to a patient discharged from their ward but open to another part of the pathway. Staffing levels on the wards have since increased as a response to the ‘Safer Staffing’ initiative with the aim of releasing more time to care.” Source location 2018-0411-Response-by-Pennine-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Clinical Lead passed the welfare concern to the responsible ward nurse, rather than failing to deal with it.
Verbatim wording from the response “‘The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this, given they were working on an acute in-patient psychiatric ward. It was unclear why the clinical lead did not deal with this matter as she was the person to whom the information had been initially provided.’” Source location 2018-0411-Response-by-Pennine-Care-NHS-Trust
Open published response
22 Nov 2018 Matthew Gerard Craven · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to check or understand previous engagements with Mental Health Services View source Failure to document the rationale for RAID decisions not to refer to a psychiatrist View source Lack of a challenge or escalation process for rejected psychiatric referrals View source Lack of agreed target timescales for routine psychiatric appointments View source Failure to share admission and encounter information with wider mental health services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew Gerard Craven · 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
Matthew Gerard Craven was found dead at home on 19 April 2018 after consuming pregabalin in excess of his prescribed amount; toxicology showed a fatal dose of pregabalin. Concerns included repeated rejected referrals for psychiatric assessment, the absence of a challenge or escalation process, no agreed timescales for routine appointments, limited documentation of referral decisions, and inadequate sharing and review of mental health information.
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 check or understand previous engagements with Mental Health Services
Wider context from the report “On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the rationale for RAID decisions not to refer to a psychiatrist
Wider context from the report “There had been a series of attendances at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a psychiatrist .
” Open source report × Source evidence
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 challenge or escalation process for rejected psychiatric referrals
Wider context from the report “He had long-term anxiety. Mental Health workers assessing him had repeatedly felt he needed to be seen by a psychiatrist. The referrals were rejected by the psychiatrist. There was no challenge or escalation process within the trust to deal with the situation.
” Open source report × Source evidence
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 agreed target timescales for routine psychiatric appointments
Wider context from the report “A routine psychiatric out patient was offered after his mother indicated she would make a formal complaint. The inquest heard that there were no agreed target timescales for the offering of routine appointments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share admission and encounter information with wider mental health services
Wider context from the report “On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move alcohol liaison practitioners to Stepping Hill Hospital and integrate them into the all-age liaison mental health team.
Verbatim wording from the response “Pennine Care’s alcohol liaison practitioners are moving to be based at Stepping Hill Hospital with the all age liaison mental health service and will form part of the same team which will significantly reduce the likelihood of any such concern arising again. The new model will be in place by the end of February 2019.” Source location 2018-0365-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 Set a 12-week target for offering routine appointments following review with the Lead Consultant Psychiatrist.
Verbatim wording from the response “Following review with the Lead Consultant Psychiatrist the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above.” Source location 2018-0365-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 Develop and implement a Stockport escalation process and protocol for rejected referrals and disagreements about psychiatric assessment.
Verbatim wording from the response “We will develop a process and protocol for escalation to be used within the borough of Stockport by the end of February 2019.” Source location 2018-0365-Response-by-Pennine-Care-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evidence showed RAID planned and made a psychiatric referral, although the outpatient referral was not accepted.
Verbatim wording from the response “3. There had been a series of presentations at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a Psychiatrist.” Source location 2018-0365-Response-by-Pennine-Care-NHS-Trust
Open published response
26 Jul 2018 Astonn Mitchell-Male · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of policy for patient medication monitoring and compliance View source Lack of policy for triangulation of corroborative information View source Poor or non-existent record keeping 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
Astonn Mitchell-Male · 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
Astonn Mitchell-Male, who had schizophrenia/psychosis and was living in supported accommodation, was found deceased on 1 November 2016 after police and ambulance services had been delayed in responding to a welfare concern the previous evening. The jury found that he died from multiple self-inflicted stab and incise wounds on or around the evening of 31 October 2016 following a deterioration in his mental state. Concerns included the absence of a Trust policy on medication monitoring and compliance, and poor or non-existent record keeping affecting patient safety.
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 policy for patient medication monitoring and compliance
Wider context from the report “1. There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for triangulation of corroborative information
Wider context from the report “1. There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor or non-existent record keeping
Wider context from the report “2. There was evidence to show that record keeping was poor and at some points non-existent . Records are a vital form of communication about the patient's condition and care provision. As such, poor compliance goes to the issue of patient safety .
” Open source report
25 Jul 2018 Paul Robert Allan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Failure to consult or work with drug and alcohol advisory services View source Failure to transfer people between community mental health teams when they move View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Robert Allan · 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 16 July 2017, Paul Robert Allan walked onto the track at Oxford Circus tube station and was struck by a westbound train. Concerns included his discharge from the Rochdale Community Mental Health Team without transfer to the corresponding team in Stoke, and a failure to consult or work with drug and alcohol advisory 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 Failure to consult or work with drug and alcohol advisory services
Wider context from the report “2) The Rochdale community Mental Health Team failed to consult or work with the Drug and Alcohol advisory services in relation to Paul Robert Allan as it is required to do.
” Open source report × Source evidence
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 transfer people between community mental health teams when they move
Wider context from the report “1) The Rochdale Community Mental Health Team discharged Paul Robert Allan from their care instead of transferring him to the Community Mental Health Team in Stoke where Paul Robert Allan was moving to.
” 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 Continue development meetings between drug and alcohol and Rochdale mental health operational managers to support and enhance the dual-diagnosis model.
Verbatim wording from the response “The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations. As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the drug and alcohol services and Rochdale mental health services are supporting and enhancing this model.” Source location 2018-0251-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 Develop new posts to bridge dual-diagnosis service gaps and establish pathways and effective working practices between mental health and drug and alcohol services.
Verbatim wording from the response “The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations. As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the drug and alcohol services and Rochdale mental health services are supporting and enhancing this model.” Source location 2018-0251-Response-by-Pennine-Care-NHS-Trust
Open published response
Concerns raised 2 Failure of escalation mechanisms to enable early action on excessive CBT waiting lists View source Insufficient capacity for people referred for CBT 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
John Paul Derwent · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Paul Derwent was referred for cognitive behavioural therapy while the waiting time was 12 months against a six-week target. He expressed suicidal ideation, was admitted and later discharged into the community; on 13 November 2017 he was found suspended from a ligature at home. The report raised concerns about insufficient CBT capacity, the substantial waiting list and escalation mechanisms that did not allow early action.
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 of escalation mechanisms to enable early action on excessive CBT waiting lists
Wider context from the report “The Inquest heard that the target time for an appointment for CBT should be 6 weeks. At the time Mr Derwent was referred, the waiting time was 12 months. There was a waiting list review in October 2017 when it was established that 500 people were on the waiting list for CBT. The waiting list time at the date of the Inquest remained 12 months. The Inquest heard that there was insufficient capacity for the number of people referred for CBT which is why the waiting list had become so significant. It was unclear why the list had been allowed to increase to this level. The mechanisms for escalation between the commissioning body and the service provider did not appear to allow for early action to address the issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for people referred for CBT
Wider context from the report “The Inquest heard that the target time for an appointment for CBT should be 6 weeks. At the time Mr Derwent was referred, the waiting time was 12 months. There was a waiting list review in October 2017 when it was established that 500 people were on the waiting list for CBT. The waiting list time at the date of the Inquest remained 12 months. The Inquest heard that there was insufficient capacity for the number of people referred for CBT which is why the waiting list had become so significant . It was unclear why the list had been allowed to increase to this level. The mechanisms for escalation between the commissioning body and the service provider did not appear to allow for early action to address the issue.
” Open source report
Concerns raised 4 Lack of a clear system for joined-up discharge planning between primary and secondary mental health services View source Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance View source Unavailability of identified mental health support services because they were not commissioned View source Failure to use one Trust-wide IT system for information sharing between professionals involved in care 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
Adrian Jennings · 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
Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.
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 clear system for joined-up discharge planning between primary and secondary mental health services
Wider context from the report “2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health 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 of the Lorenzo electronic booking and triage system to capture key information about police conveyance
Wider context from the report “4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system. Any trust operating the Lorenzo system will struggle to capture this information at booking in
” Open source report × Source evidence
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 identified mental health support services because they were not commissioned
Wider context from the report “3. a need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service ; and
” Open source report × Source evidence
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 one Trust-wide IT system for information sharing between professionals involved in care
Wider context from the report “1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust , which impacted on information sharing between professionals involved in his care ;
” Open source report
14 Mar 2018 Peter STOJILJKOVIC · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of consistent and clear prescribing guidance across local and national lists View source Risk of patients obtaining melatonin from unlicensed internet sources View source Failure to communicate with community GPs before discharge about ongoing melatonin prescribing 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
Peter STOJILJKOVIC · 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
Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.
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 consistent and clear prescribing guidance across local and national lists
Wider context from the report “2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists . It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
” Open source report × Source evidence
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 of patients obtaining melatonin from unlicensed internet sources
Wider context from the report “4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it . This created a risk that he would have to access the drug from unlicensed sources.
” Open source report × Source evidence
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 communicate with community GPs before discharge about ongoing melatonin prescribing
Wider context from the report “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community ;
2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources.
5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community.
” Open source report
13 Mar 2018 Catherine Kennedy · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to consistently use a communication paradigm for the content and documentation of key communications with off-ward on-call staff View source Insufficient measures to prevent miscommunications and assumptions in telephone conversations between ward staff and on-call doctors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Catherine Kennedy · 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
Catherine Kennedy, who had bipolar affective disorder, died after consuming more than 60 paracetamol tablets while on leave from hospital and subsequently being medically reviewed over 14 hours after staff were informed of the overdose. The report identified concerns about miscommunication and assumptions during telephone conversations between ward staff and on-call doctors, including the inconsistent use of a structured communication and documentation method.
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 consistently use a communication paradigm for the content and documentation of key communications with off-ward on-call staff
Wider context from the report “Whilst the Trust has taken a number of actions in response to its internal investigation into the circumstances of Mrs Kennedy’s death, it is a matter of residual concern that sufficiently robust measures have not yet been taken to adequately reduce the risk of future deaths arising from miscommunications and assumptions occurring in the context of telephone conversations between ward staff and on-call doctors.
In particular, it is a matter of concern that the Trust does not appear to consistently have in use a communication paradigm (such as the SBAR paradigm introduced by the United States Navy and widely of application across the NHS) as to the content and documentation of key communications , particularly arising in the context of seeking action from an on-call member of staff not based on the 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 Insufficient measures to prevent miscommunications and assumptions in telephone conversations between ward staff and on-call doctors
Wider context from the report “Whilst the Trust has taken a number of actions in response to its internal investigation into the circumstances of Mrs Kennedy’s death, it is a matter of residual concern that sufficiently robust measures have not yet been taken to adequately reduce the risk of future deaths arising from miscommunications and assumptions occurring in the context of telephone conversations between ward staff and on-call doctors .
In particular, it is a matter of concern that the Trust does not appear to consistently have in use a communication paradigm (such as the SBAR paradigm introduced by the United States Navy and widely of application across the NHS) as to the content and documentation of key communications, particularly arising in the context of seeking action from an on-call member of staff not based on the ward.
” 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 Consider adding SBAR(D) to the Trust Physical Health Policy.
Verbatim wording from the response “• Consideration to the SBAR(D) being added to the Trust Physical Health Policy.” Source location 2018-0075-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 Teach SBAR(D) communication across clinical risk, life support, suicide prevention, restraint, rapid tranquilisation and matron clinical skills courses.
Verbatim wording from the response “The Trust can confirm that the Situation, Background, Assessment, Recommendation (Decision) tool is currently taught within the following courses within Pennine Care NHS Foundation Trust:-” Source location 2018-0075-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 Add SBAR(D) to the junior doctor induction pack.
Verbatim wording from the response “• SBAR(D) to be added to junior doctor induction pack.” Source location 2018-0075-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 Supply SBAR(D) telephone pads and place them by telephones as prompts for handing over to on-call medics.
Verbatim wording from the response “• Organisational Learning and Development have been supplying learners with a copy of the A5 SBAR(D) telephone pads, to write on as handing over. The pads are placed by the telephone to provide a prompt to anyone making the call to an on-call medic.” Source location 2018-0075-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 Display SBAR(D) posters by ward office telephones for staff reference.
Verbatim wording from the response “• Wards to have a copy of the SBAR(D) poster displayed by the office telephone for staff reference.” Source location 2018-0075-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 Develop and share a seven-minute briefing on using SBAR(D) when ward staff seek action from off-ward on-call doctors.
Verbatim wording from the response “However, to further support the use of this communication tool in the context of ward staff seeking action from an on-call doctor not based on the ward, the following recommendations have been made:” Source location 2018-0075-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 Include SBAR(D) in the Handover Guidelines being developed for ward staff.
Verbatim wording from the response “• SBAR(D) to be included within the Handover Guidelines being developed for ward staff by the Modern Matron.” Source location 2018-0075-Response-by-Pennine-Care-NHS-Trust
Open published response
Concerns raised 5 Failure to enter engagement notes into the electronic system contemporaneously View source Failure to verify and coordinate necessary referrals from the 136 suite to the GP View source Failure to make documentation accessible to all relevant staff View source Failure to retain contemporaneous engagement notes View source Failure to keep records of information provided verbally by Police Officers in the s.136 suite View source See 2 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
Lindsey Theresa Hassall · 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
Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.
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 enter engagement notes into the electronic system contemporaneously
Wider context from the report “• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time . The inquest was told that the electronic system was updated from the notes after her death . Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL)
” Open source report × Source evidence
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 verify and coordinate necessary referrals from the 136 suite to the GP
Wider context from the report “• The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or 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 make documentation accessible to all relevant staff
Wider context from the report “• The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care which meant that the full history of engagement was not known to workers dealing with her .
” Open source report × Source evidence
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 retain contemporaneous engagement notes
Wider context from the report “• Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager . (Lifeline/CGL)
” Open source report × Source evidence
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 keep records of information provided verbally by Police Officers in the s.136 suite
Wider context from the report “• There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioners in the s.136 suite. The inquest heard that there was a record of the initial circumstances but no further record was kept . (Pennine Care)
” Open source report
16 Nov 2017 John Haines · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Delays in access to Healthy Minds due to long waiting times View source Lack of access to qualified psychological therapy for mental health in-patients View source Lack of access to qualified psychological therapy for patients under the care of 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
John Haines · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.
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 Delays in access to Healthy Minds due to long waiting times
Wider context from the report “3. Timely access to Healthy Minds is also hindered by long waiting times .
” Open source report × Source evidence
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 access to qualified psychological therapy for mental health in-patients
Wider context from the report “1. During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist , despite the fact that this has been raised in previous Regulation 28 PFD Forms.
Notably, all clinicians were of the professional view that psychological therapy was critical to treatment, alongside psychiatric care.
” Open source report × Source evidence
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 access to qualified psychological therapy for patients under the care of the Home Treatment Team
Wider context from the report “2. Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (‘HTT’) etc. The only way for patients to get access to a Psychologist is through referral to ‘Healthy Minds’. Healthy Minds cannot provide access where the patient remains under the care of the HTT etc.
” Open source report
5 Jun 2017 David Ian Hamilton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to document or record therapy selection options and rationale View source Lack of clarity of triggers for referrals other than group therapy View source Failure to make referrals to sleep clinic services for insomnia View source Lack of a clear formal escalation process for concerns held by health professionals View source Limited information sharing between health professionals to identify service access and need for psychiatric referral View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Ian Hamilton · 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 Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.
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 document or record therapy selection options and rationale
Wider context from the report “1. Healthy Minds had no documentation or system of recording the selection process for therapy including the options given and rationale for the choice of therapy ;
” Open source report × Source evidence
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 of triggers for referrals other than group therapy
Wider context from the report “2. There was a lack of clarity of triggers for referrals other than group therapy ;
” Open source report × Source evidence
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 referrals to sleep clinic services for insomnia
Wider context from the report “4. Referrals were not made to sleep clinic services to assist with insomnia
” Open source report × Source evidence
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 formal escalation process for concerns held by health professionals
Wider context from the report “5. There was no evidence of a clear formal escalation process where concerns were held by a health professional
” Open source report × Source evidence
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 between health professionals to identify service access and need for psychiatric referral
Wider context from the report “3. The system of sharing information between health professionals (the GP and Healthy Minds) to identify if the correct services were being accessed or if a referral to a psychiatrist was required was limited and meant that those involved did not have a full picture of his mental health;
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Initiate a case-note process recording completion of treatment-options sessions, selected treatment modalities, and allocation to the appropriate treatment pathway.
Verbatim wording from the response “An additional process will be initiated whereby a case note shall clearly state in the patients clinical records that the patient has completed a treatment options session and has chosen 1:1/CBT/Group Interventions (identifying the treatment selected) and has been allocated to the appropriate treatment pathway.” Source location 2017-0180-Response-by-Pennine-Care-NHS-Trust
Open published response
15 Mar 2017 Michael Roy Mahon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a system to identify missed annual clozapine tests 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
Michael Roy Mahon · 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
Michael Roy Mahon was found dead at home on 13 September 2016 after a period of deteriorating health and obesity while prescribed clozapine. The inquest heard that he had not received an annual test required for people prescribed clozapine, and that there was no system to identify the missed test or that it had not been noticed during monthly checks. The recorded cause of death was dilated cardiomyopathy, with obesity and clozapine therapy, and alcohol use also listed.
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 system to identify missed annual clozapine tests
Wider context from the report “In the course of the inquest I heard evidence that both annual and monthly tests should be undertaken where clozapine has been prescribed. The annual test was required to identify symptoms and potential side effects that would not necessarily be picked up on monthly tests. Michael Mahon had not had his annual test. This should have taken place in March 2016.It was accepted that there was no system to identify that the test had been missed and it was not noticed at any of his monthly checks .
” Open source report
16 Feb 2017 Thomas Josef Green · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to consider and action referrals to Adult General Psychiatry View source Lack of commissioned services for complex PTSD and complex presentations View source Insufficient detail in GP referral documentation to identify case complexity View source Lack of treatment plans addressing complex PTSD View source Inappropriate referral of complex PTSD presentations to Healthy Minds View source Lack of psychiatric follow-up after hospital discharge 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
Thomas Josef Green · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD 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 Failure to consider and action referrals to Adult General Psychiatry
Wider context from the report “1. It was unclear why a referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient, there was no evidence that this referral was ever considered or actioned .
” Open source report × Source evidence
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 commissioned services for complex PTSD and complex presentations
Wider context from the report “5. The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr Green.
” Open source report × Source evidence
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 detail in GP referral documentation to identify case complexity
Wider context from the report “4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.
” Open source report × Source evidence
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 treatment plans addressing complex PTSD
Wider context from the report “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD .
” Open source report × Source evidence
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 Inappropriate referral of complex PTSD presentations to Healthy Minds
Wider context from the report “3. When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD .
” Open source report × Source evidence
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 psychiatric follow-up after hospital discharge
Wider context from the report “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD.
” Open source report
8 Dec 2016 Sandra Brotherton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to record objections to sharing confidential medical information View source Delays in obtaining urgent Consultant Psychiatrist assessment for a person with a dual diagnosis View source Failure to attempt timely contact with a Mental Health service user after a suggestion that he needed to leave home immediately View source Lack of a clearly discussed contingency plan for interruption of sole-carer provision View source Failure to maintain a clear documented record that the Mental Health Service Care plan should be provided to an integral Personal Assistant View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Brotherton · 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
Sandra Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.
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 record objections to sharing confidential medical information
Wider context from the report “2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be 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 Delays in obtaining urgent Consultant Psychiatrist assessment for a person with a dual diagnosis
Wider context from the report “3) It was concerning that the Care Co-Ordinator who visited ████████ in August 2014 was not able to obtain an urgent appointment with a Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with a dual diagnosis was required . Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014
” Open source report × Source evidence
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 attempt timely contact with a Mental Health service user after a suggestion that he needed to leave home immediately
Wider context from the report “4) Having heard the evidence as to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of an assault but suggestive of a potential issue involving a Mental Health service user and it is for this reason that I do find that there should have been an attempt to see or speak to ████████ to see how he was , after there had been a suggestion that he needed to leave his home immediately
” Open source report × Source evidence
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 clearly discussed contingency plan for interruption of sole-carer provision
Wider context from the report “1) Knowing that Sandra was in effect a sole carer there should have been a clearly discussed contingency plan for ████████ in the event that there was an emergency and Sandra was not able to provide care .
” Open source report × Source evidence
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 a clear documented record that the Mental Health Service Care plan should be provided to an integral Personal Assistant
Wider context from the report “2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them . If there is an objection to confidential medical information being shared by the relevant person, where there is no suggestion of a lack of capacity, this should be recorded.
” 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 Disseminate and deliver a briefing on Personal Assistant involvement in care planning and information-sharing records.
Verbatim wording from the response “To share the learning highlighted in this regulation a 7 minute briefing regarding the involvement of a PA in care planning processes has been developed and has been shared with all community based mental health teams in the Trust. The briefing recommends that where a Personal Assistant is integral to the Mental Health Service” Source location 2016-0400-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 Disseminate and deliver a briefing on contingency planning when a main carer cannot provide care.
Verbatim wording from the response “To share the learning highlighted in your concern a 7 minute briefing has been developed regarding contingency plans in the absence of the main carer and this has been shared with all community based mental health teams in the Trust. The briefing recommends that where a service user’s carer in the community is reliant on the support of a carer, a contingency plan should be agreed and documented in the care plan for when the main carer is not able to provide care. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implication for individual practitioners practice and for the service or team. Practitioners have been asked to outline the steps they will take to improve practice in line with the recommendation.” Source location 2016-0400-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 Amend and implement the Trust records audit to test contingency, crisis-management, risk-mitigation and carer-communication arrangements.
Verbatim wording from the response “The Trust records audit has been reviewed and amended. This has gone live within services from week commencing 30.01.17. Question 26 of the audit asks if there are detailed actions to take to manage/mitigate risk (e.g. triggers/crisis and risk management plans). Question 26 also asks if a crisis management / contingency / prevention plan is in place.” Source location 2016-0400-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 Require Care Coordinators to assess risk-based information sharing with Personal Assistants and document this in wellbeing care plans.
Verbatim wording from the response “Care Coordinators within Stockport Community Services have been reminded that in line with the CPA policy, version 12, where a Personal Assistant is in place with individual service users, the Care Coordinator will assess the need to share information with the PA based on risk. This must form part of the wellbeing care plan.” Source location 2016-0400-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 Require Care Coordinators to develop contingency plans with identified carers and document them in service users’ care plans.
Verbatim wording from the response “Care Coordinators within Stockport Community Services have been reminded that it is their responsibility to develop contingency plans in collaboration with the identified carer in the event of any emergency situation where they are unable to provide care, such as the care being admitted to hospital. Care Coordinators will ensure this is clearly documented in the service user’s care plan.” Source location 2016-0400-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 Discuss adding Personal Assistant care-planning and information-sharing guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
Verbatim wording from the response “To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team.” Source location 2016-0400-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 Disseminate and deliver a briefing on triggers and escalation processes for responding to crisis calls.
Verbatim wording from the response “To share the learning highlighted in this regulation a 7 minute briefing regarding response to crisis calls has been developed regarding crisis calls and has been shared with all community based mental health teams in the Trust. The briefing recommends that community teams need to have triggers for responding to crisis calls and an escalation process in place. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implications for individual practitioners practice and for the service or team. They have been asked to outline the steps they will take to improve practice in line with the recommendation.” Source location 2016-0400-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 Complete and use Stockport Community Services’ process for responding to crisis calls as a model for other boroughs’ guidance.
Verbatim wording from the response “Work around responding to crisis calls completed by Stockport Community Services will feed into the Tier 4 meeting for other boroughs to develop similar guidance locally. Confirmation will be sought that community teams in other boroughs have a process for responding to crisis calls.” Source location 2016-0400-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 Discuss adding crisis-call response guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
Verbatim wording from the response “To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team.” Source location 2016-0400-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 Discuss adding contingency-planning guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
Verbatim wording from the response “To be discussed at the Tier 4 (Trust-Wide Strategic Group, which oversees Community Mental Health Services) meeting to discuss adding guidance as an addendum to current operational policy for each community based team.” Source location 2016-0400-Response-by-Pennine-Care-NHS-Trust
Open published response
8 Dec 2016 Rachal Marie Murphy · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to undertake annual liver function tests View source Failure to review CAF documentation View source Lack of clarity about referral routes and acceptance by Psychological services View source Delays in reporting EEGs View source Delays in allocation of cases within Early Help Services View source Lack of understanding of cases suitable for CAMHS referral View source Lack of GP involvement in inter-agency case handling View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rachal Marie Murphy · 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
Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.
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 annual liver function tests
Wider context from the report “1. There was a failure to undertake annual liver function tests in 2014 and 2015
” Open source report × Source evidence
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 review CAF documentation
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this 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 Lack of clarity about referral routes and acceptance by Psychological services
Wider context from the report “1. There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals .
” Open source report × Source evidence
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 Delays in reporting EEGs
Wider context from the report “3. There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in allocation of cases within Early Help Services
Wider context from the report “1. The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved .
” Open source report × Source evidence
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 cases suitable for CAMHS referral
Wider context from the report “2. Lack of understanding amongst medical professionals as to the cases which may or may not be suitable for referral to CAMHS .
” Open source report × Source evidence
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 GP involvement in inter-agency case handling
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case .
” 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 Manage Healthy Young Minds referrals through a single point of entry and allocate them according to children’s needs.
Verbatim wording from the response “As part of the Trust’s quality improvement work during early 2016 the Trust implemented a new referral process for all aspects of Tameside and Glossop Healthy Young Minds Services (formally CAMHS). All referrals are now managed via one single point of entry and then allocated to a range of possible professionals dependant on the child/young person’s needs e.g. Psychologists, Nurse, Psychiatrist or 3rd sector services. This allows for greater clarity and understanding of where to direct requests for help to for all professionals.” Source location 2016-0401-Responses
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 Expand the service offer document to name a contact for paediatric colleagues seeking advice and consultation.
Verbatim wording from the response “The document has just recently been reviewed and will be expanded to provide a named contact for colleagues in the Paediatric medical services to contact for advice and consultation. The Trust believes that this addresses the confusion and lack of understanding that you have identified in relation to Rachel’s care and treatment.” Source location 2016-0401-Responses
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 Produce and widely disseminate a Healthy Young Minds service offer document explaining referrals, advice access and appropriate referral problems.
Verbatim wording from the response “The Trust have also produced a service offer document which details, how to make a referral, how to contact the service for advice and importantly the document contains information of the types of problems that are appropriate to refer to Tameside and” Source location 2016-0401-Responses
Open published response
7 Dec 2016 Dominic Adam Travis · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 4 Lack of specialist inpatient provision for young adults with mental health problems View source Lack of transparency in internal investigations of patient care incidents View source Lack of independence in internal investigations of patient care incidents View source Delays in completing investigations and learning lessons from patient safety incidents 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
Dominic Adam Travis · 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
Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.
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 specialist inpatient provision for young adults with mental health problems
Wider context from the report “1. Department of Health:
Dominic was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-65.
Given:
i) the very stark differences between the mental health needs of younger adults and older adults,
ii) an overall increase in the levels of vulnerability in such young people (by virtue of their age, condition, varying levels of maturity etc.),
iii) that acute psychiatric ward environments often care for older adult patients with profound and enduring mental health problems (that are extremely frightening to the younger adult inpatient)
&
iv) the very different mental health requirements of young people,
I am concerned that the needs of the latter are not being appropriately or adequately met, in the absence of specialist/specialist inpatient provision.
The vulnerability of young adults is clearly recognised and acknowledged in other areas such as young offenders under the age of 21 who are sentenced to YOI establishments rather than being sent to an adult prison, however no such recognition appears to exist in relation to young adults with mental health 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 Lack of transparency in internal investigations of patient care incidents
Wider context from the report “2. Pennine Care NHS Foundation Trust:
The internal investigation into the circumstances surrounding Dominic's death was inadequate as it lacked transparency and independence. The manager to whom the investigation was allocated subsequently delegated it to a Nurse who had been directly involved in Dominic's care - he was the HTT attending clinician on the 17th May when Dominic absconded in a floridly psychotic state.
The incident was ‘STEIS reported’ but nothing further heard in this regard.
Whilst the Trust’s Medical Director has agreed to direct that a fresh investigation into the care that Dominic received be conducted (by an independent team), it became apparent during the course of the inquest that ‘lower level’ investigations are still being conducted by those directly involved in the patient’s care – it was said - to final constraints. When potentially near-neutral alternatives were discussed, the Trust confirmed that it was already considering such options but that it had no fixed plans or timescale for implementation.
Given that time is of the essence in terms of ‘lessons learned’ from such investigations – even those purportedly described as ‘low level’ - any delays potentially go to a) patient safety and/or b) the prevention 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 independence in internal investigations of patient care incidents
Wider context from the report “2. Pennine Care NHS Foundation Trust:
The internal investigation into the circumstances surrounding Dominic's death was inadequate as it lacked transparency and independence. The manager to whom the investigation was allocated subsequently delegated it to a Nurse who had been directly involved in Dominic's care - he was the HTT attending clinician on the 17th May when Dominic absconded in a floridly psychotic state.
The incident was ‘STEIS reported’ but nothing further heard in this regard.
Whilst the Trust’s Medical Director has agreed to direct that a fresh investigation into the care that Dominic received be conducted (by an independent team), it became apparent during the course of the inquest that ‘lower level’ investigations are still being conducted by those directly involved in the patient’s care – it was said - to final constraints. When potentially near-neutral alternatives were discussed, the Trust confirmed that it was already considering such options but that it had no fixed plans or timescale for implementation.
Given that time is of the essence in terms of ‘lessons learned’ from such investigations – even those purportedly described as ‘low level’ - any delays potentially go to a) patient safety and/or b) the prevention 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 Delays in completing investigations and learning lessons from patient safety incidents
Wider context from the report “2. Pennine Care NHS Foundation Trust:
The internal investigation into the circumstances surrounding Dominic's death was inadequate as it lacked transparency and independence. The manager to whom the investigation was allocated subsequently delegated it to a Nurse who had been directly involved in Dominic's care - he was the HTT attending clinician on the 17th May when Dominic absconded in a floridly psychotic state.
The incident was ‘STEIS reported’ but nothing further heard in this regard.
Whilst the Trust’s Medical Director has agreed to direct that a fresh investigation into the care that Dominic received be conducted (by an independent team), it became apparent during the course of the inquest that ‘lower level’ investigations are still being conducted by those directly involved in the patient’s care – it was said - to final constraints. When potentially near-neutral alternatives were discussed, the Trust confirmed that it was already considering such options but that it had no fixed plans or timescale for implementation.
Given that time is of the essence in terms of ‘lessons learned’ from such investigations – even those purportedly described as ‘low level’ - any delays potentially go to a) patient safety and/or b) the prevention of future deaths.
” Open source report
29 Feb 2016 Susan Beverley George · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 11 Failure to involve the patient’s Primary/Associate Nurse in discharge View source Failure to review discharge decisions after material changes in patient presentation View source Inadequacy of the discharge policy View source Poor nursing advocacy for patients View source Absence of protocol or guidance for inpatient contact with emergency services View source Disjointed and uncoordinated discharge processes View source Poor nursing record keeping View source Failure to follow the discharge policy View source Unprofessional staff attitudes towards patients and care provision View source Unavailability of an inpatient Clinical Psychologist service View source Staff unawareness of how to support patients seeking a second medical opinion View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Develop staff briefing and guidance on accessing support, advocacy, second opinions, Triangle of Care principles and multidisciplinary-team involvement.
Stated plannedThe respondent said that this action was planned when they made their response on 29 February 2016. View source
Action
Undertake a targeted organisational development review to embed a positive ward culture and support team development.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016. View source
Action
Implement a robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.
Stated completedThe respondent said that this action was complete when they made their response on 29 February 2016. View source
Action
Develop agreed staff protocol and guidance for responding when service users contact emergency services via 999, including risk review and safeguarding actions.
Stated plannedThe respondent said that this action was planned when they made their response on 29 February 2016. View source
Action
Pilot a nursing shift pattern assigning the meetings nurse dedicated time to complete discharge documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016. View source
Action
Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.
Stated plannedThe respondent said that this action was planned when they made their response on 29 February 2016. View source
Action
Fully implement monthly ward-level Standard of Record Keeping audits with supervision feedback, performance monitoring and benchmarking.
Stated completedThe respondent said that this action was complete when they made their response on 29 February 2016. View source See 4 more actions
×
AI-generated summary
Susan Beverley George · 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 Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.
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 involve the patient’s Primary/Associate Nurse in discharge
Wider context from the report “2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate 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 review discharge decisions after material changes in patient presentation
Wider context from the report “1. No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in Susan’s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled.
” Open source report × Source evidence
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 Inadequacy of the discharge policy
Wider context from the report “3. The Discharge Policy was perfunctory and staff failed to follow it in any event.
” Open source report × Source evidence
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 nursing advocacy for patients
Wider context from the report “7. Poor advocacy on the part of the nursing staff whose decisions appear to have been clouded by the rigidity of the medical decision to 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 Absence of protocol or guidance for inpatient contact with emergency services
Wider context from the report “5. There is no protocol/guidance on what steps should be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment/management.
” Open source report × Source evidence
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 Disjointed and uncoordinated discharge processes
Wider context from the report “2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate 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 Poor nursing record keeping
Wider context from the report “4. Poor record keeping, predominantly on the part of the nursing staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the discharge policy
Wider context from the report “3. The Discharge Policy was perfunctory and staff failed to follow it in any event.
” Open source report × Source evidence
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 Unprofessional staff attitudes towards patients and care provision
Wider context from the report “6. Unprofessional staff attitudes towards patient/care provision – two qualified nurses involved in Susan’s care used inappropriate language and demonstrated negative ways of thinking during both conversations with colleagues and the police communications operator. Prevailing attitudes such as this, particularly towards vulnerable adult, puts care standards at risk.
” Open source report × Source evidence
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 an inpatient Clinical Psychologist service
Wider context from the report “9. There is no inpatient Clinical Psychologist service available within Pennine Care . This is the second (possibly third) PFD Form on the same issue. The Trust maintains that this is as a result of commissioning issues. Without inpatient clinical psychology, there is a marked service gap that puts patients such as Susan at risk.
” Open source report × Source evidence
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 Staff unawareness of how to support patients seeking a second medical opinion
Wider context from the report “8. Staff were unaware of how to support and advise patients on the issue of obtaining a second medical opinion where the patient disagrees with the first doctor’s decision (in this case, to proceed to discharge).
” 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 Develop staff briefing and guidance on accessing support, advocacy, second opinions, Triangle of Care principles and multidisciplinary-team involvement.
Verbatim wording from the response “To develop a briefing on guidelines for staff to follow on how service users can access support if they are unhappy with the decision made about their care.” Source location Susan-George-Response
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 Undertake a targeted organisational development review to embed a positive ward culture and support team development.
Verbatim wording from the response “There have been some specific actions taken as regards the two nurses identified via the coroner. Although of course we cannot divulge the full details of this action it is appropriate to the allegations highlighted and being managed through the Trusts Conduct and Disciplinary processes and the NMC Fitness to Practice processes. In relation to the overall culture and attitudes on the ward, as previously mentioned the ward now has a substantive ward manager who has instilled a more proactive and positive culture but it is recognised that ward environments have many challenges, with difficulties cases to manage safely, staffing levels and acuity challenges and the need to have a stabilised ward team to foster a positive culture led by senior clinical leaders who are excellent role models and instil expectations” Source location Susan-George-Response
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 robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.
Verbatim wording from the response “The ward has appointed a substantive Ward Manager since this case and the development of a more robust discharge process has now been implemented.” Source location Susan-George-Response
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 agreed staff protocol and guidance for responding when service users contact emergency services via 999, including risk review and safeguarding actions.
Verbatim wording from the response “5. There is no protocol/guidance on what steps to be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment and management.” Source location Susan-George-Response
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 Pilot a nursing shift pattern assigning the meetings nurse dedicated time to complete discharge documentation.
Verbatim wording from the response “All relevant parties are informed of the planned discharge with the patients’ consent. This is also in line with the revised Mental Health Act Code of Practice 2015.
We are also undertaking a pilot of shift pattern for nurses which means the ‘meetings’ nurse will work 08:30–10:00 in order to ensure full completion of discharge documentation by the same staff member and thus avoids this task being handed over to a nurse who may not have been involved in the discharge meeting. This is supported with the development of the Triangle of Care initiatives, in which the involvement of family members providing information regarding the patient, even if the service user does not give consent to share information, is still included in the information that informs the discharge process.” Source location Susan-George-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.
Verbatim wording from the response “The current discharge protocol will be reviewed to ensure it is still reflective of all required processes and add a note of guidance to staff should they be faced with a similar situation.” Source location Susan-George-Response
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 Fully implement monthly ward-level Standard of Record Keeping audits with supervision feedback, performance monitoring and benchmarking.
Verbatim wording from the response “Since this case the ward has now appointed a substantive ward manager and has fully implemented the Standard of Record Keeping audit on the ward. This process includes each set of notes being audited on a monthly basis with individual results being fed back to each named nurse/qualified nurse during their supervision with any performance issues being addressed and monitored through this process. This” Source location Susan-George-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Psychological input is available through weekly ward sessions and psychology student placements, despite no dedicated full-time inpatient clinical psychologist.
Verbatim wording from the response “PCFT acknowledges there is no dedicated Clinical Psychologist available to the inpatient unit on a full time basis. This is due in part to the level of funding available to the service.” Source location Susan-George-Response
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 A dedicated full-time inpatient clinical psychologist cannot currently be provided partly because available service funding is limited.
Verbatim wording from the response “PCFT acknowledges there is no dedicated Clinical Psychologist available to the inpatient unit on a full time basis. This is due in part to the level of funding available to the service.” Source location Susan-George-Response
Open published response
12 Nov 2015 Guy Jeffrey Robinson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of Trust-wide staff familiarity with the AWOL protocol and process View source Failure to apply the AWOL protocol appropriately and in a timely manner View source Unavailability of direct inpatient access to Clinical Psychology Service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Guy Jeffrey Robinson · 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
Guy Jeffrey Robinson, a 31-year-old man with mental and physical health problems, left a mental health ward on leave on 10 July 2014 and did not return. He was found deceased outdoors on 15 July 2014; the inquest found the cause of death to be multiple drug toxicity and exposure. Concerns included delay and inadequate familiarity with the AWOL protocol, and a lack of direct inpatient access to Clinical Psychology 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 Trust-wide staff familiarity with the AWOL protocol and process
Wider context from the report “1. The ‘AWOL’ protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process . Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this 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 apply the AWOL protocol appropriately and in a timely manner
Wider context from the report “1. The ‘AWOL’ protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this 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 Unavailability of direct inpatient access to Clinical Psychology Service
Wider context from the report “2. Clinical Psychology Service - the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met - i) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team . There is no inpatient Clinical Psychology facility and no ability for hospital clinicians to refer a patient directly . This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people e.g. those who are of no fixed abode.
” 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 Share the revised AWOL Policy with staff and provide a flowchart explaining when to contact police about patients who do not return from leave.
Verbatim wording from the response “I have been assured by both In-Patient Service Manager for the North (Oldham/Rochdale/Bury) and the South (Stockport/Tameside) that this information has been shared and staff are familiar with the policy. In order to assist staff a flowchart has been produced as part of the policy, which also explains to staff when to contact the police to inform them of a patient who has not returned from leave (attached).” Source location 2015-0432-Response
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 revised AWOL Policy Trust-wide, incorporating additional guidance on actions required when a person goes absent without leave.
Verbatim wording from the response “Following the Trust’s investigation, the Absence without Leave (AWOL) Policy was reviewed and additional guidance included in relation to actions that should be taken when a person goes AWOL. This policy was initially piloted within the Trust’s Mental Health In-Patient Unit at Tameside General Hospital. The revised policy was implemented Trust wide on the 1st April 2015.” Source location 2015-0432-Response
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 In-patient Psychological Therapies are available through appropriate referrals, and a home address is not required during admission.
Verbatim wording from the response “- There is access to Psychological Therapies on the ward, which takes the form of consultation, assessment and formulation and supervision for staff who are providing psychologically informed support to patients.” Source location 2015-0432-Response
Open published response
10 Jul 2015 Dorothy McDermott · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of care staff training in the examination and care of pressure sores View source Failure to ensure suitable placements guaranteeing a place of safety for vulnerable individuals 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
Dorothy McDermott · 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
Dorothy McDermott, who was 80 and had been housebound for 2½ years, fell three times at home and was placed in emergency respite care. The care home provided residential but not nursing care, and staff were not trained to examine or care for pressure sores. An inquest concluded that opportunities to examine her sacrum were missed, and she died in hospital after developing a Grade 4 pressure sore and septicaemia.
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 care staff training in the examination and care of pressure sores
Wider context from the report “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.
Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
” Open source report × Source evidence
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 suitable placements guaranteeing a place of safety for vulnerable individuals
Wider context from the report “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.
Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
” Open source report
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Mc Guigan · 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
Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced 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 Lack of recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been 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 understanding of overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” Open source report × Source evidence
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 and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” Open source report × Source evidence
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 training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
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 understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” Open source report × Source evidence
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 disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” Open source report × Source evidence
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 and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” Open source report × Source evidence
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 national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military 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 record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and 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 Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” Open source report × Source evidence
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 Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
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 Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” Open source report × Source evidence
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 recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” 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 clinical staff attending multi-agency meetings with adequate time to review case information and contribute to discussions and action planning.
Verbatim wording from the response “Clinical staff who are required to attend multi-agency meetings now have adequate time to access and assimilate pertinent information from case notes to be able to effectively contribute to the discussion and any subsequent action planning.” Source location 2015-0185-Response-by-Pennine-Care-NHS-Trust
Open published response
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” Open source report × Source evidence
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 explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” Open source report × Source evidence
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 return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any 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 Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective 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 initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” Open source report × Source evidence
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 pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” Open source report × Source evidence
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 safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” Open source report × Source evidence
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 availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” Open source report × Source evidence
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 recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” Open source report × Source evidence
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 youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” Open source report × Source evidence
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 police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” Open source report × Source evidence
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 legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” Open source report × Source evidence
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 safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” Open source report × Source evidence
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 safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” Open source report × Source evidence
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 police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” Open source report × Source evidence
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 route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” Open source report × Source evidence
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 understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” Open source report × Source evidence
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 interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between 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 provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” Open source report × Source evidence
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 differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” Open source report × Source evidence
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 document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” Open source report × Source evidence
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 Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” Open source report × Source evidence
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 officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Lack of a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Expand the fortnightly multi-agency vulnerable-offender panel to include children and young people and consider diversion from the criminal justice system.
Verbatim wording from the response “4. The multi-agency panel for vulnerable offenders which meets every two weeks now also has capacity to deal with children and young people. Individuals are discussed during these local meetings and ways in which they can be diverted from the criminal justice system considered. The emphasis now is to ensure children do not remain in police custody or other penal institutions.” Source location 2015-0143-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 Republish and promote the health diversion pathway to Tameside Police and the Youth Offending Team.
Verbatim wording from the response “3. The health diversion pathway has been re-published and re-promoted to Tameside Police and the Youth Offending Team to increase use of the pathway.” Source location 2015-0143-Response-by-Pennine-Care-NHS-Trust
Open published response
30 Sep 2014 Derek Hawkins · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 1 Lack of objective risk-factor rating in the risk assessment tool 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
Derek Hawkins · 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 Hawkins, who had bipolar disorder and was admitted for reassessment and treatment after increased suicidal thoughts, disclosed on 22 November 2013 that he intended to hang himself. He left the ward unescorted on 24 November and was found hanging in a derelict building near the hospital grounds that evening. The concerns included failures in communication, unclear leave arrangements, inadequate risk assessment after his disclosure of suicidal intent, and a risk-assessment tool that relied on subjective practitioner 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 Lack of objective risk-factor rating in the risk assessment tool
Wider context from the report “(1) The Risk Assessment tool currently in use relies on an individual practitioner’s subjective assessment and description of risk factors . The tool does not provide a means of objectively rating risk factors and means that less experienced practitioners may fail to recognise or identify an increase in risk .
” Open source report
18 Mar 2014 David Gary Chatburn · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 9 Failure to make case-specific referrals through the single point of entry process View source Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning View source Unnecessarily bureaucratic and deterrent processes for accessing mental health services View source Unavailability of direct referral to in-house community-based psychiatrists for new patients View source Failure to ensure medically qualified practitioner management of single point of entry triage View source Restrictions on cross-Clinical Commissioning Group referrals without special approval View source Failure of contemporaneous record keeping to support clinical recollections View source Failure to use recognised assessment tools in clinical evaluation View source Failure to assess medication appropriateness in light of patients’ mental health history 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
David Gary Chatburn · 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 Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health 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 Failure to make case-specific referrals through the single point of entry process
Wider context from the report “4. That the GP felt it was sufficient for him to simply discuss the deceased’s care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process . Such discussions were not necessarily case specific in any event but rather, general in nature .
” Open source report × Source evidence
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 refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning
Wider context from the report “1. That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan . The GP considered that there was no need, as he felt clinically competent to manage the deceased’s care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest (‘GPwSPi’) and whilst confident in his ability to manage the deceased’s care, his area of special interest was in fact the management of addictions.
Irrespective, he felt that he was best placed to assess, diagnose and treat the deceased on the basis that had he referred Mr Chatburn to the single point of entry system, the person ‘triaging’ would not have been medically qualified and would not have known the deceased as well as he felt he did.
” Open source report × Source evidence
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 Unnecessarily bureaucratic and deterrent processes for accessing mental health services
Wider context from the report “7. That the processes GPs are expected to use in order to access mental health services for their patients are unnecessarily bureaucratic and deterrent . GPs can no longer simply contact a Consultant Psychiatrist directly for advice. Everything must pass through the single point of entry.
” Open source report × Source evidence
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 direct referral to in-house community-based psychiatrists for new patients
Wider context from the report “3. That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist , thus effectively defeating the object.
” Open source report × Source evidence
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 medically qualified practitioner management of single point of entry triage
Wider context from the report “8. That the ‘triage’ process used by the single point of entry system is not always managed by a medically qualified practitioner – this being a vital stage in determining diversion/allocation .
” Open source report × Source evidence
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 Restrictions on cross-Clinical Commissioning Group referrals without special approval
Wider context from the report “9. That GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same . In order to do so, a ‘special case’ must be argued . This potentially limits patient (and practitioner) accessibility and treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of contemporaneous record keeping to support clinical recollections
Wider context from the report “5. That the GP’s recollection of events was not supported by contemporaneous record keeping , thus calling into question accuracy.
” Open source report × Source evidence
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 recognised assessment tools in clinical evaluation
Wider context from the report “6. That the GP did not use a recognised assessment tool, as an adjunct or otherwise, in his clinical evaluation of the deceased . He felt that they were ineffective and of little, if any, value.
” Open source report × Source evidence
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 medication appropriateness in light of patients’ mental health history
Wider context from the report “2. That the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient’s past mental health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists.
” 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