Concerns raised 4 Failure to take sufficient steps to persuade patients detained under the Mental Health Act who refuse necessary and appropriate medical treatment View source Insufficient action in response to routine food refusal by patients detained under the Mental Health Act 1983 View source Failure to sufficiently consider using section 63 of the Mental Health Act 1983 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment View source Failure to sufficiently consider powers under the Mental Capacity Act 2005 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kevin Anthony Ince · 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
Kevin Anthony Ince was detained under the Mental Health Act 1983 and became unwell at Kem Ple View Hospital on 24 October 2023. He was taken to hospital, where his condition deteriorated, and he died on 25 October 2023 from right ventricular failure caused by acute interstitial pneumonitis associated with vaping-related lung injury. The concerns included insufficient consideration of responses when detained patients refused necessary medical treatment and insufficient action when a detained patient routinely declined food over a prolonged period.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to take sufficient steps to persuade patients detained under the Mental Health Act who refuse necessary and appropriate medical treatment
Wider context from the report “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient , insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983
(2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient action in response to routine food refusal by patients detained under the Mental Health Act 1983
Wider context from the report “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983
(2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently consider using section 63 of the Mental Health Act 1983 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment
Wider context from the report “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983
(2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently consider powers under the Mental Capacity Act 2005 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment
Wider context from the report “(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983
(2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period.
” 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 Operate and review a database weekly to monitor food and fluid intake, with documented actions when patients refuse adequate nutrition.
Verbatim wording from the response “A database has also been created at Kemple View to capture data about patients who are monitored using food and fluid intake charts: this will facilitate a more thorough review as to whether adequate nutrition is being accepted by the patient. This database is now reviewed weekly during an extended hospital handover meeting, with actions documented in accordance with the flowchart where a nutritional diet is refused.” Source location Response from The Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the poor-diet-and-fluid-intake flowchart to include capacity, best interests, family involvement and section 63 considerations.
Verbatim wording from the response “Following Mr Ince’s death, a ‘Management of Poor Diet and Fluid Intake’ flowchart was also introduced at Kemple View. I understand this was also explained by the Hospital Director during the inquest. This flowchart shows the process to follow when a patient has inadequate diet and fluid intake, to include escalation to the Responsible Clinician for discussion and referral to the Dietician for advice. The patient’s capacity to refuse an adequate nutritional diet is to be assessed and where the patient is deemed to be without capacity, a best interest meeting is to be arranged. All decision making is to be documented.” Source location Response from The Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a staff briefing on good nutrition and fluid intake at Priory Hospital Kemple View.
Verbatim wording from the response “A Priory dietician is scheduled to complete a briefing to Priory Hospital Kemple View staff in January 2025 on the topic of good nutrition and fluid intake.” Source location Response from The Priory
Open published response
12 Aug 2024 Mr David Thompson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to identify absence of NHS community services when formulating the ongoing plan View source Failure to open the four standard care plans during inpatient stay View source Failure to commence and complete a safety plan during admission and before discharge View source Failure to engage the local Home Based Treatment Team before discharge View source Lack of ability to access relevant parts of medical records View source Failure of consultant-to-consultant communication across NHS and private care View source Failure to investigate nursing staff and determine whether care failures reflect individual or system failure View source Failure to consult treating consultants across Priory locations View source Failure to make a 48-hour post-discharge follow-up call View source Failure to consider regulatory referral of individuals View source Failure to undertake an internal review for learning from the admission View source Failure to discuss the reasons for rapid relapse with the patient View source Failure to provide crisis information at discharge View source Failure to complete the discharge clinical entry and risk assessment View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr David Thompson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to identify absence of NHS community services when formulating the ongoing plan
Wider context from the report “2. At the time of his appointment in January 2024 Mr Thompson was not under any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to open the four standard care plans during inpatient stay
Wider context from the report “6. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to commence and complete a safety plan during admission and before discharge
Wider context from the report “1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to engage the local Home Based Treatment Team before discharge
Wider context from the report “2. There was no engagement prior to discharge with the local Home Based Treatment Team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of ability to access relevant parts of medical records
Wider context from the report “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information . Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure of consultant-to-consultant communication across NHS and private care
Wider context from the report “1. There was a complete absence of any Consultant – Consultant discussions or communication , given this patient was receiving care from both the NHS and privately .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate nursing staff and determine whether care failures reflect individual or system failure
Wider context from the report “7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out . There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure . Nor was consideration given to whether any individuals should be reported to their regulatory body.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to consult treating consultants across Priory locations
Wider context from the report “3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to make a 48-hour post-discharge follow-up call
Wider context from the report “4. There was no 48 hour follow up call to Mr Thompson following his discharge , as per Priory Policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to consider regulatory referral of individuals
Wider context from the report “7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an internal review for learning from the admission
Wider context from the report “3. No internal review was undertaken of Mr Thompsons admission within the Priory Altrincham to consider whether there was any learning
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss the reasons for rapid relapse with the patient
Wider context from the report “1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide crisis information at discharge
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the discharge clinical entry and risk assessment
Wider context from the report “5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to complete discharge clinical entries, risk assessments, checklists and crisis-information provision in accordance with policy.
Verbatim wording from the response “Priory Hospital Dorking are to evidence safe discharge planning in accordance with Priory policy H02 Admission, Transfer and Discharge - to include completion of a clinical entry, updated risk assessment on discharge and issue all patients with a crisis card with” Source location Response from Priory Group
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 an admission-template field prompting clinicians to identify current NHS or private service involvement.
Verbatim wording from the response “Priory expect that when a consultant psychiatrist or doctor is gathering background psychiatric information from a patient at the point of their first assessment, professional curiosity should guide the conversation to ascertain whether the patient is currently receiving care or treatment from any other care provider (NHS or private services). Despite recognising this, patients may not wish to disclose the facts of previous or current episodes of treatment for a number of reasons. This is their right.” Source location Response from Priory Group
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 Remind staff to maintain four core care plans and review completion through daily dashboard checks and audits.
Verbatim wording from the response “Issue a reminder to all staff regarding the expectation that all patients have the four core care plans in place throughout the hospital admission.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct separate service-level Team Incident Reviews involving staff involved in care and consolidate findings at a senior-manager joint meeting for cross-service learning.
Verbatim wording from the response “It was recognised that Mr Thompson had been a recent patient at both Priory Hospital Altrincham and Priory Hospital Dorking and hence why it was considered at the time that inviting representatives from both services to attend a joint TIR was good practice. On reflection, we conclude that we should have hosted a separate TIR at each service, inviting those involved in the care and treatment of the patient (to include nursing colleagues), and thereafter brought together the key findings at a joint meeting attended by the senior managers, to identify any areas for cross service learning. This learning point has since been reiterated to Priory’s Director of Quality and our regional Associate Directors of Nursing and Quality who are responsible for the commissioning and quality review of TIR’s.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate a reminder explaining how to access patients’ entire CareNotes records.
Verbatim wording from the response “This concern was addressed in the action plan that was imbedded within the TIR report and this was shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on CareNotes (Priory’s electronic patient records platform), the system defaults to show only active documents. This is intended to ensure only records relevant to the current episode of care are present. To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A reminder of the presence of this function has since been circulated to all Priory colleagues and a prompt to select ‘entire record’ will be added to the admission checklist.” Source location Response from Priory Group
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 Remind staff to confirm and document Community Mental Health Team engagement and follow-up arrangements before discharge.
Verbatim wording from the response “Issue a reminder to all staff regarding the expectation that referrals to a patient’s community team are to be clearly confirmed and documented on CareNotes prior to a patient’s discharge.” Source location Response from Priory Group
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 guidance on identifying and liaising with external care providers through network meetings, circulated minutes and a learning cascade.
Verbatim wording from the response “To ensure this learning point is reiterated to all consultants across Priory, the importance of identification and liaison (where appropriate) with external organisations involved in the care and treatment of a patient was raised at:” Source location Response from Priory Group
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 Remind staff to complete required My Safety Plans and monitor compliance through daily dashboard reviews and audits.
Verbatim wording from the response “Issue a reminder to all staff the requirement to complete a My Safety Plan, and to outline the circumstances when a My Safety Plan is required.” Source location Response from Priory Group
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 Remind clinicians to obtain and consider patients’ background history and involvement of other services at admission.
Verbatim wording from the response “Issue a reminder to all staff regarding the expectation that a patient’s background history is gained and understood at the point of admission.” Source location Response from Priory Group
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 a prompt to select the CareNotes ‘Entire Record’ tab to the admission checklist.
Verbatim wording from the response “This concern was addressed in the action plan that was imbedded within the TIR report and this was shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on CareNotes (Priory’s electronic patient records platform), the system defaults to show only active documents. This is intended to ensure only records relevant to the current episode of care are present. To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A reminder of the presence of this function has since been circulated to all Priory colleagues and a prompt to select ‘entire record’ will be added to the admission checklist.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide crisis cards at discharge by ordering replacement stock and using written or telephone-stored crisis numbers while awaiting delivery.
Verbatim wording from the response “contact details of services they can contact in a crisis.” Source location Response from Priory Group
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 Contact with external care organisations depends on the information available and the patient's consent.
Verbatim wording from the response “Upon receipt of details about any external services involved in a patient’s care, it may be appropriate to make contact with these organisations but this will be dependent on the detail of the information made available and whether the patient consents to such contact being made.” Source location Response from Priory Group
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 Sharing correspondence with the patient's GP is considered sufficient because the GP remains the central coordinator and other services can request information through it.
Verbatim wording from the response “It is important to mention that whilst Priory have made advances to the systems and process in place to gather these details and encourage our multi-disciplinary teams to facilitate such contact (with patient consent), all correspondence relating to a patient’s admission, discharge and outpatient care is shared with a patient’s GP (with patient consent). The patient’s GP remains the central coordinator of a patient’s care. Other care services involved in a patient’s care and treatment can request access to this information via the GP. Should an external service (whether private or NHS) seek additional detail to the information held by the GP, Priory clinicians will make themselves available, at short notice if required, to engage in discussions about a patient’s care and treatment.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No individual referral to a regulatory body was considered necessary in this instance under the Just Culture approach.
Verbatim wording from the response “Matter of concern 7 - limitations of internal review” Source location Response from Priory Group
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 48-hour follow-up call is not required where a confirmed NHS community appointment exists within 72 hours of discharge.
Verbatim wording from the response “Matter of concern 4 - 48 hour follow up call” Source location Response from Priory Group
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 review of the Altrincham admission was undertaken and concluded that inpatient care was adequate and discharge was appropriate.
Verbatim wording from the response “Matter of concern 3 - internal review following incident” Source location Response from Priory Group
Open published response
15 May 2024 Mr Benjamin Sulzbacher · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Unclear eligibility for NHS discharge service referral for private paying inpatients View source Lack of understanding of NHS community discharge services 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 Benjamin Sulzbacher · 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 Benjamin Sulzbacher had experienced deteriorating mental health and was admitted to a private hospital after attempting to tie a ligature at home. After discharge, no referral was made to the NHS Home Based Treatment Team, and he died after tying a ligature on 27 September 2023. Concerns included uncertainty among services about NHS discharge support for private inpatients and a lack of understanding at the Priory about the community services available.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Unclear eligibility for NHS discharge service referral for private paying inpatients
Wider context from the report “1. It was unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS . The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. Importantly the face to face contact enables a better understanding of how a patient is actually presenting when considering their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of NHS community discharge services
Wider context from the report “1. There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge . The court heard that the Home Based Treatment Team was understood to simply be a “Crisis team” which was incorrect .
” Open source report
21 Apr 2023 Amy Henderson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of clarity about responsibility for identifying and removing banned and restricted items at admission View source Lack of rapid access to NHS records on admission to a private hospital 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
Amy Henderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amy Henderson, who had been diagnosed with post-partum depression and admitted to Priory Hospital, Woking after expressing suicidal thoughts and plans, died there on 21 March 2022 after taking her own life by suspension in a disabled toilet. Concerns included risk assessments and observations not being completed in line with policy, therapy notes indicating deterioration not being acted upon, incomplete information about her suicide risk, and ineffective management of the disabled toilet as a high-risk area.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for identifying and removing banned and restricted items at admission
Wider context from the report “2. The Priory Woking has a policy in relation to the removal of banned and restricted items but there was a lack of clarity and confusion among the clinicians as to who was responsible for ensuring that such items are identified and removed from the patient at admission .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of rapid access to NHS records on admission to a private hospital
Wider context from the report “1. The information that Miss Henderson had practised tying a ligature was divulged by her at Kingston Hospital but not repeated on admission to the Priory Woking. The evidence given at the inquest was that there is no quick method to obtain NHS records on admission to a private hospital . A request could have been made but the records would have taken over a week to be released . The records were not sought. An ability to obtain the NHS records quickly would have been of assistance to the Priory clinicians .
” Open source report
27 Feb 2023 Peter Gary SEABY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to conduct an internal review following an unexpected resident death View source Insufficient staffing levels for resident care and supervision View source Failure to formalise allocation of resident supervision and meal preparation duties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Gary SEABY · 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 Gary Seaby was a resident of The Oaks and Woodcroft Care Home who died in hospital on 22 May 2018 after choking-related symptoms and subsequent aspiration pneumonia. His lunchtime food was not prepared in accordance with his SALT Care Plan, and he did not receive the required one-to-one supervision; the inquest found these possibly contributed to his death. The report also identified concerns about informal care arrangements, staffing levels, and the absence of an internal review after his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an internal review following an unexpected resident death
Wider context from the report “3. Mr Seaby died in 2018 and this is the second inquest into Mr Seaby’s death. There has still been no internal review carried out following Mr Seaby’s death which was unexpected. No Manager was present throughout the inquest and when some elements of evidence were put in dealing with Regulation 28 matters there was some surprise at some of the points raised in evidence heard during the course 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels for resident care and supervision
Wider context from the report “2. It was not clear from the evidence that the staffing levels at Oaks and Woodcroft Care Home are sufficient to provide care for residents, including those requiring one to one supervision and supervision out of the Home and to cover individual activities
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise allocation of resident supervision and meal preparation duties
Wider context from the report “1. Evidence was heard at the inquest of the “informal approach” taken with regard to arrangements as to who would provide supervision of residents, including on a one to one basis and who would cook and prepare their meals, including those residents who were subject to a specific SALT dietary plan . Evidence was also heard of steps which have been put in place since Mr Seaby’s death to provide written staff rotas for such matters, prepared by Team Leaders and Deputy Managers. However, despite these steps being taken, evidence was also heard at the inquest from staff, who continue to provide care at Oaks and Woodcroft Care Home, referring to providing care on an “informal basis” and that this “works”.
” 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 Create a detailed action plan arising from the internal review.
Verbatim wording from the response “In respect of taking this review forward, our operational management team are to now closely consider the findings of your Inquest and other information made available about the tragic incident involving Mr Seaby. The review will assist the operational management team to draw out any salient themes and trends that still exist despite the overarching improvements made and the passage of time. A detailed action plan will be created and any significant learning points will be shared with colleagues at the home and also be shared more widely across Priory services as appropriate.” Source location Response from Priory
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt and embed the Patient Safety Incident Response Framework across Priory Adult Care.
Verbatim wording from the response “• Priory are in the process of adopting the Patient Safety Incident response Framework (PSIRF). This will assist Priory to better examine incident themes and trends and respond proportionately to incidents to achieve the most learning. We anticipate that PSIRF will be fully embedded across Priory Adult Care by Autumn 2023.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Inquest findings and related information to identify remaining themes and trends.
Verbatim wording from the response “Our operational management team have now had an opportunity to meet with our legal representatives following the Inquest and this meeting highlighted several salient points that were raised, not least the requirement for a review to be undertaken of this matter as you have outlined.” Source location Response from Priory
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 Recruit an additional Investigations Officer to support reviews and investigations.
Verbatim wording from the response “• Priory are recruiting an additional Investigations Officer to assist in undertaking reviews and investigations.” Source location Response from Priory
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 staffing numbers against colleague feedback, resident support plans and resident needs.
Verbatim wording from the response “Our operational management team, together with the home management team, regularly review staffing levels at each of our homes, for example prior to the admission of a new resident and in response to the deterioration of a resident’s health. The operational management team have taken this opportunity to review staffing numbers again in response to your report, by consulting with the home management team, seeking feedback from colleagues at the home and reviewing resident support plans and considering resident needs. We are satisfied that staffing levels at The Oaks and Woodcroft Care Home are satisfactory, that staff are being effectively allocated to care for residents and that staffing numbers are sufficient to ensure that residents are safe and well looked after.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report all serious incidents through escalation arrangements and coordinate next-day discussions on communication, support and investigations.
Verbatim wording from the response “• All serious incidents are ‘reported up’. Where necessary a meeting is held the next working day after a serious incident is identified with discussion held in respect of communication with family, staff support and investigation arrangements.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen role allocation, mealtime responsibilities and staff handover processes following staff feedback and debriefing.
Verbatim wording from the response “Since the Inquest we have offered support to the staff member and explored with her what ████████ meant by the term ‘informal’. We have asked her to identify the areas of day-to-day practice that ████████ feels would benefit from being made more precise. More widely, the staff team as a whole have been given feedback, as part of the debrief process, on the outcome and learning from the Inquest and have been asked for their views on resident care and what, if any, improvements need to be made. This exercise has resulted in some additional improvements having been made in terms of the process for allocation of roles, staff understanding their roles and responsibilities particularly at mealtimes and the process for staff handovers having been strengthened.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct mealtimes in two sittings to enable closer supervision while residents eat and drink.
Verbatim wording from the response “On a practical level, meal times are now undertaken in two sittings to enable closer supervision of each resident whilst eating and drinking.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report and review incidents and near misses, identifying improvement areas and lessons learned.
Verbatim wording from the response “• Arrangements to promptly report and review each incident and ‘near-miss’ incident.” Source location Response from Priory
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 Staffing levels and allocation are considered sufficient to keep residents safe, supported by contingency staffing and on-call management arrangements.
Verbatim wording from the response “Our operational management team, together with the home management team, regularly review staffing levels at each of our homes, for example prior to the admission of a new resident and in response to the deterioration of a resident’s health. The operational management team have taken this opportunity to review staffing numbers again in response to your report, by consulting with the home management team, seeking feedback from colleagues at the home and reviewing resident support plans and considering resident needs. We are satisfied that staffing levels at The Oaks and Woodcroft Care Home are satisfactory, that staff are being effectively allocated to care for residents and that staffing numbers are sufficient to ensure that residents are safe and well looked after.” Source location Response from Priory
Open published response
17 Jul 2022 James John Jude Booth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to complete and transfer adverse-event information through shift handovers View source Lack of national guidance on perimeter fencing and security for outside areas of mental health locked wards View source Failure to maintain a safe and secure garden perimeter for vulnerable patients View source Failure to audit and robustly review handover documents View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James John Jude Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Booth, who had longstanding mental ill-health and was detained at The Priory, Altrincham, absconded on 7 October 2020 and was found dead on 14 October 2020; the medical cause of death was hanging. The principal concerns were inadequate security of the ward garden, including the fence, inadequate risk assessments, and failures to communicate and document repeated incidents and emerging risk between shifts.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and transfer adverse-event information through shift handovers
Wider context from the report “Matter Two
The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts . In particular, the form specifically designed for this with a section for completion – ‘incidents in last 7 days’ which would have provided an information flow through was not completed .
Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out. Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review. Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days . The risk of a lack of appreciation of an emerging pattern of behaviour remains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on perimeter fencing and security for outside areas of mental health locked wards
Wider context from the report “Matter One
The inquest heard that the Priory had identified that the garden fence was a risk, in particular the section over the door, in about December 2019. There had been a number of escapes both over the fence and through it, in the months leading up to James’ escape. The number of escapes indicates that garden area was not safe. There was a plan to replace it but there were other priorities.
More striking was that there is no national guidance for perimeter fencing and security for the outside areas of mental health ‘locked wards’ ; unlike that in existence for mental health ‘secure units’. In particular, the height of the fence .
While it is accepted that national guidance ought not be necessary to carry out appropriate risk assessments and ensure secure/safe spaces it is clear that such guidance is necessary to ensure the correct level of security for vulnerable patients , whilst benefitting from the therapeutic setting of an outdoor space.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a safe and secure garden perimeter for vulnerable patients
Wider context from the report “Matter One
The inquest heard that the Priory had identified that the garden fence was a risk , in particular the section over the door, in about December 2019. There had been a number of escapes both over the fence and through it , in the months leading up to James’ escape. The number of escapes indicates that garden area was not safe . There was a plan to replace it but there were other priorities.
More striking was that there is no national guidance for perimeter fencing and security for the outside areas of mental health ‘locked wards’; unlike that in existence for mental health ‘secure units’. In particular, the height of the fence.
While it is accepted that national guidance ought not be necessary to carry out appropriate risk assessments and ensure secure/safe spaces it is clear that such guidance is necessary to ensure the correct level of security for vulnerable patients, whilst benefitting from the therapeutic setting of an outdoor space.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to audit and robustly review handover documents
Wider context from the report “Matter Two
The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts. In particular, the form specifically designed for this with a section for completion – ‘incidents in last 7 days’ which would have provided an information flow through was not completed.
Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out . Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review . Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days. The risk of a lack of appreciation of an emerging pattern of behaviour remains.
” 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 safety bulletins across Priory hospitals reminding staff to record previous incidents in shift handovers.
Verbatim wording from the response “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.” Source location Response from Priory
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 courtyard and garden risk assessments across all Priory hospitals to address patient absconding risks.
Verbatim wording from the response “We note that you have directed one of your matters of concern to the Department of Health. This matter of concern relates to considering the need for having in place national guidance to ensure the correct level of security for vulnerable patients while also benefitting from the therapeutic setting of an outdoor space. In respect of this matter of concern, please be assured that Priory has responded to the risk of patients absconding by completing a series of courtyard/garden risk assessments across all Priory hospitals. There is also an ongoing programme of works at our Priory acute units to increase courtyard and garden fencing (including anti-climb roller bars) to a standard height of 3.2m.” Source location Response from Priory
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 courtyard and garden fencing at Priory acute units, including anti-climb roller bars, to 3.2 metres.
Verbatim wording from the response “We note that you have directed one of your matters of concern to the Department of Health. This matter of concern relates to considering the need for having in place national guidance to ensure the correct level of security for vulnerable patients while also benefitting from the therapeutic setting of an outdoor space. In respect of this matter of concern, please be assured that Priory has responded to the risk of patients absconding by completing a series of courtyard/garden risk assessments across all Priory hospitals. There is also an ongoing programme of works at our Priory acute units to increase courtyard and garden fencing (including anti-climb roller bars) to a standard height of 3.2m.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor handover quality through internal compliance and divisional quality inspections.
Verbatim wording from the response “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and trial an electronic handover template that consolidates patient and incident information and enables contemporaneous content audits.
Verbatim wording from the response “Additionally, a detailed handover template is being introduced across the Priory Healthcare sites (and this is currently being trialled on Rivendell ward at Altrincham in response to your Regulation 28 report). The handover template has the capacity to download information from different applications including the electronic patient record (CareNotes) and the incident reporting system (Datix). This will give a detailed picture of the patient’s current health and” Source location Response from Priory
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attend weekly ward shift handovers and check their content, accuracy and detail.
Verbatim wording from the response “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.” Source location Response from Priory
Open published response
22 Apr 2022 Matthew Alexander CASEBY · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Failure to maintain a single consistent patient record View source Failure of serious incident investigations to identify and implement critical lessons View source Inaccuracies in clinical records View source Failure to complete and update risk assessments in a timely manner by suitably experienced staff View source Unsafe courtyard layout for patient restraint View source Unsafe courtyard perimeter fence for preventing absconding and ligature risk View source Lack of standard guidelines for perimeter fences and security in acute mental health unit outside areas View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 23
Action
Install software linking Datix incident reports directly to patient CareNotes records.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Update Quality Walk Round checks to compare CareNotes risk assessments with patients’ incident profiles.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Implement a programme to increase acute-unit courtyard and garden fence heights to at least 3.2 metres and fit anti-climb roller bars where required.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Triangulate incidents with patient risk assessments and care plans through ward checks and daily flash-meeting confirmation.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Add a Datix prompt requiring confirmation that incident-related risk assessments and care plans have been reviewed.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Continue compliance inspections comparing patient risk assessments with incident reports.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Audit consistency between patient records and handover notes through compliance inspections and handover observations.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Remind staff to complete contemporaneous risk assessments through communications, supervision and appraisals.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Review and reissue Policy H62 Healthcare Records, prohibiting copying and pasting between patient records.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Update monthly Quality Walk Round assessments to check consistency between patient records and handover notes.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Require full PSIRF investigations for absconding incidents from ward gardens or courtyards.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Review incident reports and response actions through divisional Quality Improvement Leads, escalating concerns about inadequate action.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Review and reissue Beech ward courtyard and garden risk-management procedures after completing excavation works.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2022. View source
Action
Adopt and roll out the NHS Patient Safety Incident Review Framework for proportionate serious-incident investigations.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Provide updated serious-incident investigation training to all Hospital Directors.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2022. View source
Action
Audit incident reports against risk assessments and care plans weekly and review results at hospital governance meetings.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Amend 72-hour and team incident reports to document lessons learned and recurrence-prevention actions in greater detail.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Review, update and roll out risk-assessment and risk-management training covering contemporaneous documentation and real-time risk sharing.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Issue and disseminate bulletins requiring accurate records and comprehensive, consistent shift handovers.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Update and reissue Policy H35 to require prompt post-incident risk review and handover communication of resulting care-plan changes.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Update documentation Quality Walk Round checks to identify inaccurate records and copying between patient records.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Continue compliance reviews of CareNotes records for accuracy during inspections.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Excavate, level and landscape the Beech ward courtyard, install anti-climb roller bars, and ensure the fence is at least 3.2 metres high.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source See 20 more actions
×
AI-generated summary
Matthew Alexander CASEBY · 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 Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a single consistent patient record
Wider context from the report “1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. I have serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to identify and implement critical lessons
Wider context from the report “4. Serious Incidents: The inquest heard evidence that a previous absconsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focussed on why the patient absconded to have a cigarette. I have serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in clinical records
Wider context from the report “2. Record Keeping quality: There were numerous inaccuracies in Matthew’s medical records , eg his status was written as informal when he was formal, he was described as violent when he was not and was described as "she". Staff were unable to explain how that occurred. The investigation witness from the Priory thought there was an element of cutting and pasting into the records from another patient’s records. I have serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and update risk assessments in a timely manner by suitably experienced staff
Wider context from the report “3. Risk Assessments: The inquest heard how all members of staff can update a Risk Assesment at any time. Despite this, and with clear evidence that Matthew was at risk of absconsion, his risk assessment was not updated over the weekend when the risk materialised . I have serious concerns about how risk assessments are completed, when they are completed, who completes them and whether they are updated in a timely and necessary manner by suitably experienced 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Unsafe courtyard layout for patient restraint
Wider context from the report “5. Courtyard Fence: A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe. I have serious concerns that an urgent review of the courtyard is required. In addition, I heard evidence from Dr ████████ that the fence was a ligature risk. Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe especially if a patient needed to be restrained .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Unsafe courtyard perimeter fence for preventing absconding and ligature risk
Wider context from the report “5. Courtyard Fence: A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe . I have serious concerns that an urgent review of the courtyard is required. In addition, I heard evidence from Dr ████████ that the fence was a ligature risk . Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe especially if a patient needed to be restrained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of standard guidelines for perimeter fences and security in acute mental health unit outside areas
Wider context from the report “For the Department of Health
1. National guidelines for perimeter fences and security in acute mental health unit outside areas. The inquest heard evidence from Professor ████████, a specialist in safety in Mental Health settings, that it would be useful for there to be standard guidelines for the requirements of perimeter fences and security for outside areas in acute Mental Health units as no such guidance is in place . This would ensure the correct level of security for some of the most vulnerable patients whilst maintaining a therapeutic setting.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install software linking Datix incident reports directly to patient CareNotes records.
Verbatim wording from the response “Changes to the IT system: We are currently installing software in the Healthcare Division to enable the Datix incident reports to upload directly to the patient’s CareNotes record (i.e. staff will only have to record the incident on Datix and the information will automatically be copied across to the patient record). We expect this to go “live” from July 2022. This will enable colleagues to have ease of access to the incident reports via CareNotes which will facilitate preparing for and writing up shift handover documentation.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Quality Walk Round checks to compare CareNotes risk assessments with patients’ incident profiles.
Verbatim wording from the response “• The monthly Quality Walk Round template has been updated and includes reference to checks being made on CareNotes that the risk assessment accords with the patient’s incident profile.” Source location Response from Priory Group
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 programme to increase acute-unit courtyard and garden fence heights to at least 3.2 metres and fit anti-climb roller bars where required.
Verbatim wording from the response “Although your concerns were addressed to the Department of Health, I can confirm that following an internal review, we have concluded that the appropriate height for courtyard and garden fencing at our acute units is not less than 3.2 metres and we are currently implementing a programme of works to increase fence heights where required. This is expected to be carried out over the next 12 months. We also consider it appropriate for anti-climb roller bars to be fitted at the top of each fence.” Source location Response from Priory Group
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 Triangulate incidents with patient risk assessments and care plans through ward checks and daily flash-meeting confirmation.
Verbatim wording from the response “Checks by Ward Staff: At Woodbourne, the nurse in charge of the ward (or the on-site manager during weekends and “out-of-hours”) checks reported incidents and triangulates these with the patient risk assessments and risk management plans. Similarly, all incidents that have occurred in the previous 24 hours are highlighted during the morning ‘flash’ meeting (these meetings take place Monday to Friday and are attended by the SMT together with representatives from each ward). The meetings act as a prompt to ward managers to check that such incidents have been reported on Datix and CareNotes and considered within the patient’s risk assessment and care plan. This is then confirmed the following day at the next flash meeting.” Source location Response from Priory Group
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 a Datix prompt requiring confirmation that incident-related risk assessments and care plans have been reviewed.
Verbatim wording from the response “Changes to Datix: The Datix incident reporting system now has a prompt in place asking the staff member reporting the incident to confirm whether the patient’s risk assessment and associated care plans have been reviewed in response to the incident.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue compliance inspections comparing patient risk assessments with incident reports.
Verbatim wording from the response “• The internal compliance team will continue to review patient risk assessments (which form part of the CareNotes records) against incident reports during their inspections.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit consistency between patient records and handover notes through compliance inspections and handover observations.
Verbatim wording from the response “Monitoring: Implementation of these actions will be monitored by the following means:” Source location Response from Priory Group
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 Remind staff to complete contemporaneous risk assessments through communications, supervision and appraisals.
Verbatim wording from the response “Communications to staff: All colleagues at Woodbourne have been reminded about the requirement to complete contemporaneous risk assessments. This has also been raised with colleagues as part of supervision and where necessary, appraisals.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and reissue Policy H62 Healthcare Records, prohibiting copying and pasting between patient records.
Verbatim wording from the response “Changes to Policy: Policy H62 Healthcare Records has been reviewed and re-issued. The policy also makes reference to the fact that “cutting and pasting” between patient records is not acceptable.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update monthly Quality Walk Round assessments to check consistency between patient records and handover notes.
Verbatim wording from the response “• The monthly Quality Walk Round template has been updated so that patient records and handover notes will be assessed for consistency. A Quality Walk Round involves a senior member of the hospital team scrutinising particular areas of ward practice using sampling methodology.” Source location Response from Priory Group
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 full PSIRF investigations for absconding incidents from ward gardens or courtyards.
Verbatim wording from the response “Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSIRF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.” Source location Response from Priory Group
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 incident reports and response actions through divisional Quality Improvement Leads, escalating concerns about inadequate action.
Verbatim wording from the response “Monitoring: The following checks are being undertaken to ensure that there is an appropriate response to incidents:” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and reissue Beech ward courtyard and garden risk-management procedures after completing excavation works.
Verbatim wording from the response “Management Procedures: The existing Beech ward courtyard/garden risk management procedures will be reviewed and updated upon completion of the excavation works. It is expected that the procedures will be re-issued during week commencing Monday 21 June 2022.” Source location Response from Priory Group
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 Adopt and roll out the NHS Patient Safety Incident Review Framework for proportionate serious-incident investigations.
Verbatim wording from the response “Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSIRF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide updated serious-incident investigation training to all Hospital Directors.
Verbatim wording from the response “Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSIRF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit incident reports against risk assessments and care plans weekly and review results at hospital governance meetings.
Verbatim wording from the response “• Woodbourne is undertaking a weekly audit of a sample of incident reports which are checked against risk assessments and care plans. Results are reviewed at the weekly hospital governance meetings.” Source location Response from Priory Group
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 72-hour and team incident reports to document lessons learned and recurrence-prevention actions in greater detail.
Verbatim wording from the response “72-Hour Reports: Priory has amended the 72-hour incident report and team incident reporting system to ensure that these document in more detail the lessons learnt from incidents and the actions taken to prevent a re-occurrence of such incidents.” Source location Response from Priory Group
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 roll out risk-assessment and risk-management training covering contemporaneous documentation and real-time risk sharing.
Verbatim wording from the response “Training: We have initiated a review of our risk assessment and risk management training e-learning module and this will be updated and rolled out during H2 of 2022. The module will include a requirement to ensure that risk assessments and risk management plans are contemporaneous and accurate and that patient risk is shared in “real-time” with all colleagues.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and disseminate bulletins requiring accurate records and comprehensive, consistent shift handovers.
Verbatim wording from the response “Communications to staff: During May 2022 two bulletins were issued to all colleagues in the Healthcare Division via the Priory intranet. The first bulletin, issued as part of the monthly Safety First initiative, emphasised the importance of accurate and detailed record keeping. The second bulletin detailed the importance of conducting thorough and comprehensive shift handovers. The bulletins each emphasise that the content of the daily care record must correspond with the content of the handover record. The bulletins have been discussed at Woodbourne governance meetings and in staff supervision.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and reissue Policy H35 to require prompt post-incident risk review and handover communication of resulting care-plan changes.
Verbatim wording from the response “Changes to Policy: During May 2022, we incorporated the issues learned from the inquest into Policy H35 Clinical Risk Assessment which has been updated and re-issued. For example, there is now a reference to the risk assessment and risk management plan being reviewed by the senior member of the team as soon as practicable after an incident and this review must be completed before the end of the current shift. The outcome of the risk assessment and any subsequent changes to the care plan (which may include an increase in observation levels) must be communicated to the next shift at handover.” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update documentation Quality Walk Round checks to identify inaccurate records and copying between patient records.
Verbatim wording from the response “• The monthly documentation Quality Walk Round template has been updated and includes a requirement for accuracy checks to be carried out on CareNotes records (including ensuring there is no “cutting and pasting” between patient records).” Source location Response from Priory Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue compliance reviews of CareNotes records for accuracy during inspections.
Verbatim wording from the response “Monitoring: The following checks are being undertaken to ensure that records are accurate:” Source location Response from Priory Group
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 Excavate, level and landscape the Beech ward courtyard, install anti-climb roller bars, and ensure the fence is at least 3.2 metres high.
Verbatim wording from the response “Ongoing Works: Excavations of the Beech ward courtyard, to include levelling off and landscaping, began shortly after the conclusion of the Inquest. These works were finished on 10 June 2022 and will eliminate the areas where there is banking adjacent to the fence: i.e. the courtyard mesh fence will be” Source location Response from Priory Group
Open published response
17 Dec 2021 Nichola Jane Lomax · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 16 Under-reporting of eating disorder deaths to the coroner View source Lack of clear responsibility for monitoring and co-ordinating community eating disorder care View source Absence of an acute hospital liaison psychiatry service View source Poor and inaccurate compilation of clinical documentation View source Poor nursing care for patients with eating disorders View source Lack of dissemination and understanding of MARSIPAN guidance among medical professionals View source Lack of appropriate investigation and learning from eating disorder deaths View source Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs View source Failure to conduct incident reviews of referral failures View source Failure to closely monitor food intake and purging behaviours View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source Failure to maintain nutrition and fluid charts View source See 13 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
Nichola Jane Lomax · 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
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Under-reporting of eating disorder deaths to the coroner
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care .
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders . It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Absence of an acute hospital liaison psychiatry service
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital .
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Poor and inaccurate compilation of clinical documentation
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Poor nursing care for patients with eating disorders
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care . There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report “1) Inadequate Training of doctors and other medical professionals re eating disorders
For National / NCA / Royal College of Psychiatrists
Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient .
Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground .
Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate investigation and learning from eating disorder deaths
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths . This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Unclear Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital.
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester . However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct incident reviews of referral failures
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Absence of pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients
Wider context from the report “5) Community Monitoring of patients with an Eating Disorder
For BURY CCG / NATIONAL / ICB/ GMHSCP
There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community . The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report
27 Oct 2020 Martin Thomas BARRETT · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1 Failure to directly inform higher-risk patients when internal referrals are declined, including providing interim safety-netting advice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Thomas BARRETT · 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
Martin Thomas Barrett took part in a telephone assessment for anxiety on the morning of his death and disclosed suicidal thoughts and planning. A same-day referral for further psychiatric assessment was declined, and this decision was not communicated to him; he was later found hanging at home. The principal concern was that higher-risk patients may not be directly informed when an internal referral is declined, potentially leaving them without timely alternative treatment or safety-netting advice.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to directly inform higher-risk patients when internal referrals are declined, including providing interim safety-netting advice
Wider context from the report “During oral evidence, I was advised that when an onwards internal referral is made to another clinician within the Priory Group which is then declined this is not communicated directly to the patient if the treatment is funded by way of insurance cover. In those cases a notification would be provided to the insurers or the policyholder and then the Priory Group would not have any further contact with the patient . As such, patients that are considered to be higher risk by the clinician at initial assessment may not therefore have the opportunity to imminently consider alternative sources of treatment or receive any advice as to safety netting in the interim as this information is not being provided by clinicians to the patient. From the evidence that I heard it would be reliant on their insurers or corporate policy holders (who may well not be clinicians) to make contact with the patients to inform them of this during which time their health may have further declined or their risk increased.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide therapists with guidance on advising newly referred higher-risk clients, including the timing limitations of consultant psychiatrist assessments.
Verbatim wording from the response “Therapists have also been given guidance – similar to that outlined above – on the advice that they should give to any newly referred clients who they feel are higher risk. They have also been reminded that it is not always possible for an assessment by a consultant psychiatrist to take place on the same day as the initial therapy assessment and this needs to be taken into account when providing advice and guidance to a higher risk client.” Source location 2020-0222-Response-from-Priory-Group-REDACTED.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out periodic CCT audits of client contacts to check that documentation and communication requirements are achieved.
Verbatim wording from the response “The CCT and the therapists have been reminded that they should document their interventions and must communicate with each other and the newly referred client promptly – they should not expect this to be the responsibility of the insurer or corporate policyholder. Audits of client contacts will be carried out by the CCT from time to time in order to ensure this aim is achieved.” Source location 2020-0222-Response-from-Priory-Group-REDACTED.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require CCT staff and therapists to document interventions and communicate promptly with each other and newly referred clients.
Verbatim wording from the response “The CCT and the therapists have been reminded that they should document their interventions and must communicate with each other and the newly referred client promptly – they should not expect this to be the responsibility of the insurer or corporate policyholder. Audits of client contacts will be carried out by the CCT from time to time in order to ensure this aim is achieved.” Source location 2020-0222-Response-from-Priory-Group-REDACTED.pdf
Open published response
18 Feb 2020 Wayne Lee Millett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure of serious incident investigations to critically analyse care and treatment against the Care Plan View source Lack of clear care plans for monitoring Clozapine side-effects and directing staff response to suspected serious complications View source Failure to formally review care plans for patients prescribed Clozapine View source Failure to learn from serious clinical incidents and take action accordingly View source Failure to audit compliance with care plans View source Lack of overarching quality assurance for serious incident investigations View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Wayne Lee Millett · 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
Wayne Lee Millett, a detained patient at The Priory Hospital, Cheadle, had treatment-resistant schizophrenia treated with Clozapine and died there on 13 February 2019 after escalating abdominal symptoms, collapse and complications including pseudo-obstruction of the small bowel. The report raised concerns that the Care Plan was not followed, that the Priory’s investigation and quality-assurance processes were inadequate, and that care-plan compliance and Clozapine-related monitoring had not been sufficiently reviewed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to critically analyse care and treatment against the Care Plan
Wider context from the report “1) The Priory’s own investigation into the circumstances of Mr Millett’s death was notably lacking in meaningful critical analysis of the care and treatment he received , and in particular was fundamentally flawed in that it failed to consider the care given as against the Care Plan despite its obvious central relevance to his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of clear care plans for monitoring Clozapine side-effects and directing staff response to suspected serious complications
Wider context from the report “4) It is a matter of concern that, notwithstanding the cause of death identified on Post Mortem Examination and despite nearly a year having passed since Mr Millett’s death, the organisation has yet to formally review the care plans of all patients prescribed Clozapine, with a view to ensuring each relevant patient has in place a clear plan for monitoring of potential side-effects of the medication , which gives clear and authoritative direction to staff as to how to act if serious complications are suspected . It is a particular matter of concern that this step has not been taken, given the evidence heard from the Peripatetic Director of Clinical Services which suggested this would be a straightforward measure to accomplish, and one which could be completed within 28 days.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review care plans for patients prescribed Clozapine
Wider context from the report “4) It is a matter of concern that, notwithstanding the cause of death identified on Post Mortem Examination and despite nearly a year having passed since Mr Millett’s death, the organisation has yet to formally review the care plans of all patients prescribed Clozapine , with a view to ensuring each relevant patient has in place a clear plan for monitoring of potential side-effects of the medication, which gives clear and authoritative direction to staff as to how to act if serious complications are suspected. It is a particular matter of concern that this step has not been taken, given the evidence heard from the Peripatetic Director of Clinical Services which suggested this would be a straightforward measure to accomplish, and one which could be completed within 28 days.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from serious clinical incidents and take action accordingly
Wider context from the report “2) The above concern, when taken in conjunction with the facts that:
a) the evidence before the court confirmed the organisation’s Director of Risk Management, ████████ had input into the investigation; and
b) the Peripatetic Director of Clinical Services who gave evidence before the court was unable to describe any overarching quality assurance process operating within the organisation in respect of serious incident investigations;
This raises significant concerns as to the Priory Group’s ability to learn from serious clinical incidents and to take action accordingly , thus creating a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to audit compliance with care plans
Wider context from the report “3) The court heard differing evidence from staff working at The Priory Hospital, Cheadle and from the Peripatetic Director of Clinical Services as to what the organisation’s expectations were in respect of care plans, and specifically the degree of adherence which were required to them. In the light of this significant divergence of opinion, it is a matter of concern that the Priory Group has not undertaken any audit of compliance with care plans (either at The Priory Hospital, Cheadle or more generally within the organisation) as a result of Mr Millett’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of overarching quality assurance for serious incident investigations
Wider context from the report “2) The above concern, when taken in conjunction with the facts that:
a) the evidence before the court confirmed the organisation’s Director of Risk Management, ████████ had input into the investigation; and
b) the Peripatetic Director of Clinical Services who gave evidence before the court was unable to describe any overarching quality assurance process operating within the organisation in respect of serious incident investigations ;
This raises significant concerns as to the Priory Group’s ability to learn from serious clinical incidents and to take action accordingly, thus creating a risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the 2020 formal audit of patient care plans and analyse its results.
Verbatim wording from the response “Please note there are systems in place which ensure that patient care plans are regularly audited. These systems include Ward Managers and the Director of Compliance at each hospital having a responsibility for undertaking regular “spot-checks” by way of completing the monthly Quality Walk Rounds during which the care records of patients are reviewed and evaluated. Our Healthcare Division Quality Team also undertakes a formal annual audit of care plans. The 2020 audit was unfortunately delayed due to the Covid-19 pandemic but was completed last month with the audit results currently being analysed.” Source location 2020-0031-Response-from-Priory_Redacted
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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 Circulate incident and near-miss learning bulletins and update related policies and training courses.
Verbatim wording from the response “In the event of a very serious incident, we always undertake a rapid review of the case with the aim of taking swift action, where it is deemed necessary, to help reduce the possibility of a re-occurrence of such incidents and until such time as the completion of the more detailed investigation. We circulate frequent bulletins and messages to our staff about the lessons learnt from incidents and near misses with policies and training courses amended and updated accordingly. The improvement and embedding of any improvement actions is monitored by our Healthcare Division Quality Team who scrutinise incidents themes and trends and where necessary undertake more individualised reviews of patient care.” Source location 2020-0031-Response-from-Priory_Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver investigation and report-writing training to senior staff conducting serious incident investigations.
Verbatim wording from the response “• Delivering training to senior staff who are commissioned to complete investigations and prepare reports to ensure they have the necessary skills to identify key issues and convey those concisely and clearly in their written outputs;” Source location 2020-0031-Response-from-Priory_Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Datrix incident reporting tool to accelerate reporting and improve local and division-wide incident analysis.
Verbatim wording from the response “More generally in relation to incidents, we have systems and processes in place to ensure we learn from all incidents and near misses as expeditiously as possible. In July 2019, we invested in a new incident reporting tool (Datrix) which has assisted us to report incidents more quickly and better analyse them both locally i.e. at each hospital and across the Healthcare Division as a whole.” Source location 2020-0031-Response-from-Priory_Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior staff, including the Group Medical Director and Director of Quality, to review every draft serious incident investigation report.
Verbatim wording from the response “• Strengthening the review process so that all draft serious incident investigation reports are reviewed by a team of senior staff which in all cases includes the Group Medical Director and the Director of Quality.” Source location 2020-0031-Response-from-Priory_Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit a serious incidents investigation officer with a mandate to improve investigation processes.
Verbatim wording from the response “In relation to your concern that we are not a learning organisation, please note we continue to invest significant time and resource in making continuous improvements to the services we provide to some of the most clinically challenging mental health patients in the UK. This includes in relation to incident investigations: in March this year we recruited a highly-experienced serious incidents investigation officer (SIO) with a clear mandate to make improvements to our processes for the benefit of patients and staff including:” Source location 2020-0031-Response-from-Priory_Redacted
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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 Issue Clozapine guidelines and a care-plan template covering medication side effects and their management.
Verbatim wording from the response “As above, we are very much a learning organisation and we saw the matters raised at the Inquest concerning Mr Millett as an opportunity to review the way in which we manage the prescription and management of Clozapine. We have now allocated a Clozapine learning and development module to all doctors and qualified nurses. We have also issued Clozapine guidelines and an associated care plan “template” which gives clear details on the potential side-effects of the medication and how best to manage those.” Source location 2020-0031-Response-from-Priory_Redacted
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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 Create action plans from serious incident recommendations and have senior site staff regularly monitor their implementation.
Verbatim wording from the response “• Ensuring that action plans are drawn up based on the recommendations in the SUI report and these are monitored regularly by senior staff at site to ensure learnings are being embedded in clinical practice.” Source location 2020-0031-Response-from-Priory_Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing monthly quality walk rounds and annual audits provide regular auditing of patient care plans.
Verbatim wording from the response “Please note there are systems in place which ensure that patient care plans are regularly audited. These systems include Ward Managers and the Director of Compliance at each hospital having a responsibility for undertaking regular “spot-checks” by way of completing the monthly Quality Walk Rounds during which the care records of patients are reviewed and evaluated. Our Healthcare Division Quality Team also undertakes a formal annual audit of care plans. The 2020 audit was unfortunately delayed due to the Covid-19 pandemic but was completed last month with the audit results currently being analysed.” Source location 2020-0031-Response-from-Priory_Redacted
Open published response
10 Sep 2019 Gurdeep Singh Dundhal · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Delays in organising timely mental health assessments View source Failure to obtain and have available key information and documentation for mental health assessments View source Failure to undertake internal investigations into assessment delays and resource concerns View source Failure to engage with other agencies to learn lessons from complex cases View source Failure to place patients on the recommended Mental Health Act section View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gurdeep Singh Dundhal · 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
Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Delays in organising timely mental health assessments
Wider context from the report “1. There was a delay in organising the assessment of Mr Dundhal when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was undertaking the assessment between Walsall MBC and Birmingham City Council . In addition there was a lack of resources to enable the assessment to be carried out in a timely manner . This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and have available key information and documentation for mental health assessments
Wider context from the report “2. Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19. I was unable to confirm which at the inquest. This meant the true nature of Mr Dundhal’s long term condition was not known and the assessors were unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack of available 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake internal investigations into assessment delays and resource concerns
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19 . They have also failed to engage with other agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with other agencies to learn lessons from complex cases
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19. They have also failed to engage with other agencies to ensure lessons are learnt . It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to place patients on the recommended Mental Health Act section
Wider context from the report “3. When Mr Dundhal was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3 . No explanation was available for this . Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delays in arranging assessment, detention choice and Walsall Council’s investigation were matters for the other identified bodies to address.
Verbatim wording from the response “You will appreciate that in respect of points 1, 3 and 4, PGH is not in a position to comment and that (i) any delays in arranging the MHA assessment; (ii) the use of Section 2 rather than a Section 3 detention on admission; and (iii) the failure by Walsall MBC to undertake an investigation are matters for the other interested persons noted above to address.” Source location 2019-0294-Response-by-The-Priory
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relevant clinical information was made available to the assessing team, and no IT outage prevented access to electronic notes.
Verbatim wording from the response “In respect of point 2 and the concern in relation to key information being unavailable or not asked for, please note that clinical staff at Lakeside View have considerable experience in liaising with professionals undertaking Mental Health Act assessments and have advised that relevant information relating to Mr Dundhal was made readily available to the assessing team. Additionally, Mr Dundhal’s responsible clinical ████████ made himself available on the day of the assessment and in fact was contacted by ward staff who asked him to speak to the assessing doctor, ████████.” Source location 2019-0294-Response-by-The-Priory
Open published response
31 Oct 2016 Anthony Thomas McManus · Prevention of Future Deaths report Milton Keynes
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Concerns raised 3 Failure to record observations contemporaneously View source Failure to carry out required observations View source Failure to conduct observations at varied times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Anthony Thomas McManus · 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
Anthony Thomas McManus, who was detained under Section 37 of the Mental Health Act and resident at Chadwick Lodge, was found hanging from a bathroom door using a draw string bag after he was not visible during overnight checks on 8 December 2015. Concerns were raised about the unit’s observation system, including observations being conducted at fixed times, some not being carried out, and charts being completed retrospectively.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations contemporaneously
Wider context from the report “(1) The system of observations carried out within the unit, particularly at night is in need of reform.
(2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly.
(3) Some observations were not carried out and the observation chart completed at the end of the shift .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required observations
Wider context from the report “(1) The system of observations carried out within the unit, particularly at night is in need of reform.
(2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly.
(3) Some observations were not carried out and the observation chart completed at the end of the shift.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct observations at varied times
Wider context from the report “(1) The system of observations carried out within the unit, particularly at night is in need of reform.
(2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly.
(3) Some observations were not carried out and the observation chart completed at the end of the shift.
” Open source report
15 May 2015 Sara Jane Green · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to complete medical consultation records contemporaneously View source Failure to verify the accuracy of dictated medical consultation records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sara Jane 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
Sara Jane Green died at Cheadle Royal Hospital on 18 March 2014 after being found with wire spiral binding wrapped around her neck; resuscitation was unsuccessful. The inquest identified concerns about her prolonged admission and the inadequate or unavailable provision of placements and discharge arrangements. It also identified concerns about delays in medical record-keeping, which could prevent important information from being available to staff and create a risk of harm to patients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to complete medical consultation records contemporaneously
Wider context from the report “During the course of the evidence it was discovered that the medical staff (not the nursing staff or other healthcare professionals) were not making contemporaneous records of consultations or attendances with Sara . On occasions there were days passing between a consultation and the medical record being completed .
Some examples are below:
The record of a consultation on 30 January 2014, timed to have taken place at 15:30 hours was not entered until 09:21 hours on 7 February 2014.
The record of a consultation that took place on 4 February 2014 was not entered until 7 February 2014, and was not checked for its accuracy until 10 February 2014.
The record of a consultation that took place on 25th February 2014 was not entered until 4 March 2014, and was not checked for its accuracy until 10 March 2014.
I was advised that the method of record-keeping employed is that the consultation is dictated and it is then entered into the records by a secretary. In terms of the record being checked for accuracy, the entry is then simply read by the relevant practitioner without any reference to any hand written note, nor hearing the dictation.
It was accepted by one of the doctors subscribing to such a practice that this was an unacceptable practice. That such a late entry into the records of a consultation did not comply with the General Medical Council guidelines for 'Good Medical Practice 2013'.
19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
As I understand one of the purposes of clear, accurate, legible and up-to-date record-keeping is the dissemination of information to others caring for a patient. In circumstances where days may pass before the record of a consultation/assessment is available to others caring for a patient the passing on, or easy availability, of important information will be denied. That, in my view, places patients at risk.
The evidence received on this issue at the Inquest suggests that the system of record-making has not changed but that the entry must now be completed within 24 hours of the consultation .
In my view that remains an unacceptable period of time and does not comply with the General Medical Council guideline of completing records "as soon as possible afterwards".
It was suggested to me that those healthcare professionals accompanying the medical practitioner(s) on ward rounds and at consultations would pass on any important information at a handover. I am not satisfied that this coordination of information in this manner is entirely appropriate, and that it does not adequately compensate for the lack of contemporaneity.
That a delay, of up to 24 hours, in 'writing up' the record of a medical consultation may result in important information not being available to, or easily accessible to, other healthcare professionals involved in the care of a patient , or give rise to the possibility of a misinterpretation of that information, or of the information being inaccurate, if it is passed on orally while waiting for the entry to be 'written up'. This gives rise to a risk of harm to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to verify the accuracy of dictated medical consultation records
Wider context from the report “During the course of the evidence it was discovered that the medical staff (not the nursing staff or other healthcare professionals) were not making contemporaneous records of consultations or attendances with Sara. On occasions there were days passing between a consultation and the medical record being completed.
Some examples are below:
The record of a consultation on 30 January 2014, timed to have taken place at 15:30 hours was not entered until 09:21 hours on 7 February 2014.
The record of a consultation that took place on 4 February 2014 was not entered until 7 February 2014, and was not checked for its accuracy until 10 February 2014 .
The record of a consultation that took place on 25th February 2014 was not entered until 4 March 2014, and was not checked for its accuracy until 10 March 2014 .
I was advised that the method of record-keeping employed is that the consultation is dictated and it is then entered into the records by a secretary. In terms of the record being checked for accuracy, the entry is then simply read by the relevant practitioner without any reference to any hand written note, nor hearing the dictation .
It was accepted by one of the doctors subscribing to such a practice that this was an unacceptable practice. That such a late entry into the records of a consultation did not comply with the General Medical Council guidelines for 'Good Medical Practice 2013'.
19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
As I understand one of the purposes of clear, accurate, legible and up-to-date record-keeping is the dissemination of information to others caring for a patient. In circumstances where days may pass before the record of a consultation/assessment is available to others caring for a patient the passing on, or easy availability, of important information will be denied. That, in my view, places patients at risk.
The evidence received on this issue at the Inquest suggests that the system of record-making has not changed but that the entry must now be completed within 24 hours of the consultation.
In my view that remains an unacceptable period of time and does not comply with the General Medical Council guideline of completing records "as soon as possible afterwards".
It was suggested to me that those healthcare professionals accompanying the medical practitioner(s) on ward rounds and at consultations would pass on any important information at a handover. I am not satisfied that this coordination of information in this manner is entirely appropriate, and that it does not adequately compensate for the lack of contemporaneity.
That a delay, of up to 24 hours, in 'writing up' the record of a medical consultation may result in important information not being available to, or easily accessible to, other healthcare professionals involved in the care of a patient, or give rise to the possibility of a misinterpretation of that information, or of the information being inaccurate , if it is passed on orally while waiting for the entry to be 'written up'. This gives rise to a risk of harm to the patient.
” 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 examples of good practice for completing clinical records collaboratively during consultations and multidisciplinary meetings.
Verbatim wording from the response “At the Healthcare Medical Directors’ Meeting held on Tuesday, 30 June 2015, staff were further reminded by Group Director of Safety, ████████, of the need to ensure contemporaneous record keeping including in relation to ward rounds, Care Programme Approach review meetings, multi-disciplinary team meetings, individual one-to-one consultations and assessments. A context was given for the directive and those present were reminded of the General Medical Council guidelines.” Source location 2015-0190-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring the promptness of medical staff clinical documentation through local governance, audit, supervision and appraisal arrangements.
Verbatim wording from the response “We will also continue to monitor how promptly our medical staff are documenting all service user consultations on an ongoing basis. Monitoring is undertaken as part of monthly local governance and audit arrangements. Record keeping is also routinely considered as part of medical supervision and annual appraisal.” Source location 2015-0190-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind hospital and senior management leaders across the Healthcare Division to ensure contemporaneous clinical record keeping.
Verbatim wording from the response “Prior to receipt of your PFD report and based on your comments at the inquest, on Tuesday, 12 May 2015 our Group Medical Director, ████████, wrote to the Hospital Medical Directors at all 42 of the Priory Group Healthcare Division hospitals reminding them of the requirement to ensure that service user records were completed during the course of ward rounds, Care Programme Approach review meetings and multi-disciplinary team meetings.” Source location 2015-0190-Response-by-Priory-Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a tablet-computer pilot at two hospitals for contemporaneous record keeping during clinical meetings.
Verbatim wording from the response “In addition, a pilot study has been undertaken at two of our hospitals using different types of tablet computers for use in ward rounds, Care Programme Approach review meetings and multi-disciplinary team meetings. We expect the pilot to complete by the end of this month and depending on the findings and recommendations, where appropriate we will procure any additional equipment that most effectively meets the needs of our staff. We are optimistic that having access to tablet computers should enable staff to load medical records on to the Care Notes clinical record system during or shortly after a consultation. We expect this process to be completed by Wednesday, 30 September 2015. In the meantime, where the current absence of computer access prevents immediate entry of the contemporaneous records, the meetings will continue to be documented within 2-3 hours following a consultation.” Source location 2015-0190-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider rolling out collaborative screen-based clinical record completion across appropriate Healthcare Division cases.
Verbatim wording from the response “I should add that during the meeting on 30 June 2015, aspects of good practice were identified and shared. An example of good practice was raised by one of the Medical Directors who had other colleagues of the efficiencies and positive experiences found in response to the clinical record being projected on to a screen and completed with the active involvement of the service user and the multi-disciplinary team during the meeting itself. This action enables the service user to see what is being recorded and thus helps to promote insight and his/her involvement in their care. We will consider how this practice can be rolled out across the Healthcare Division in appropriate cases.” Source location 2015-0190-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review information technology and resolve identified connectivity problems to support faster contemporaneous record updates in clinical meeting rooms.
Verbatim wording from the response “In light of your concerns, we have been reviewing how we can use information technology to enable clinicians and others to update medical records more quickly. As a starting point, tests have been carried out in relation to wi-fi capability, efficiency and security in those clinical meeting rooms across the Healthcare Division where the absence of fixed computer equipment prevents staff updating contemporaneous records during the consultation or shortly afterwards. The purpose of this is to facilitate the use of tablet computers by staff in these rooms. Where connectivity problems were identified these are either fully resolved or will be resolved by Wednesday, 30 September 2015.” Source location 2015-0190-Response-by-Priory-Group
Open published response
Concerns raised 4 Lack of staff competence and risk appreciation for patients with drug and alcohol problems receiving methadone View source Inability of prescribing doctors to undertake meaningful treatment and supervision risk assessments when patients' drugs are unknown View source Failure of internal methadone-related death inquiries to draw on external research View source Lack of drug screening for patients admitted to alcohol detoxification programmes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Peter Greenfield · 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 Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of staff competence and risk appreciation for patients with drug and alcohol problems receiving methadone
Wider context from the report “1. Not everyone involved in his care was experienced in dealing with patients who had both drug and alcohol problems and the risks of respiratory depression in patients such as the deceased were not fully appreciated . The internal enquiry undertaken by The Priory following the deceased’s death took into account experience and opinions of people within the organisation but did not draw upon research undertaken outside the organisation on the question of sudden and unexpected deaths of people taking prescribed methadone. A re-training programme had been introduced by The Priory following this death but it would seem that there remains a lack of a detailed appreciation of the risks involved of death of patients in receipt of methadone and of patients with the particular characteristics of the deceased and therefore until that understanding and appreciation of risk has been determined training which has already being investigated cannot properly deal with issues which have yet to be identified. It is therefore believed that a further review of such risk and risk management policies needs to be considered with suitable re-training introduced thereafter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Inability of prescribing doctors to undertake meaningful treatment and supervision risk assessments when patients' drugs are unknown
Wider context from the report “2. Evidence was given if a patient enters The Priory with a view to a drug treatment issue then that patient would be screened for drugs. If a patient is admitted to The Priory for an alcohol detoxification programme then there is no screening for drugs. The deceased was known to take methadone. Other drugs were found at post mortem in his system and in combination with alcohol detoxification medication there is an increased risk of respiratory depression and in the absence of the prescribing doctor knowing with a degree of certainty (notwithstanding any statements made by a patient) as to what drugs are in a patients system then a full and proper risk assessment as to the nature of the treatment to be offered and the level of supervision and observations to be instituted (i.e. a meaningful risk assessment) cannot be undertaken and this lacuna in admission procedures could well lead to an increased risk of similar fatalities in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure of internal methadone-related death inquiries to draw on external research
Wider context from the report “1. Not everyone involved in his care was experienced in dealing with patients who had both drug and alcohol problems and the risks of respiratory depression in patients such as the deceased were not fully appreciated. The internal enquiry undertaken by The Priory following the deceased’s death took into account experience and opinions of people within the organisation but did not draw upon research undertaken outside the organisation on the question of sudden and unexpected deaths of people taking prescribed methadone . A re-training programme had been introduced by The Priory following this death but it would seem that there remains a lack of a detailed appreciation of the risks involved of death of patients in receipt of methadone and of patients with the particular characteristics of the deceased and therefore until that understanding and appreciation of risk has been determined training which has already being investigated cannot properly deal with issues which have yet to be identified. It is therefore believed that a further review of such risk and risk management policies needs to be considered with suitable re-training introduced thereafter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of drug screening for patients admitted to alcohol detoxification programmes
Wider context from the report “2. Evidence was given if a patient enters The Priory with a view to a drug treatment issue then that patient would be screened for drugs. If a patient is admitted to The Priory for an alcohol detoxification programme then there is no screening for drugs . The deceased was known to take methadone. Other drugs were found at post mortem in his system and in combination with alcohol detoxification medication there is an increased risk of respiratory depression and in the absence of the prescribing doctor knowing with a degree of certainty (notwithstanding any statements made by a patient) as to what drugs are in a patients system then a full and proper risk assessment as to the nature of the treatment to be offered and the level of supervision and observations to be instituted (i.e. a meaningful risk assessment) cannot be undertaken and this lacuna in admission procedures could well lead to an increased risk of similar fatalities in the future.
” 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 detoxification hospitals with urine drug-screening kits and instruct staff to test patients where illicit-drug use is indicated.
Verbatim wording from the response “We are in agreement with you that we should routinely use urine drug screens across all of our detoxification services as part of the assessment process and where necessary on an on-going basis thereafter. Since the request we have reviewed this practice and learnt that a number of hospitals are routinely undertaking urine drug screens on those patients who are admitted for alcohol detoxification. Our intention is to ensure that our hospitals all have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs prior to or at the point of admission. Our intention is to ensure that these kits are readily available at relevant hospital sites by the end of February 2014.” Source location 2014-0518-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Source and arrange advanced-level training for Aspen Ward staff.
Verbatim wording from the response “With regard to the staff at Aspen Ward, Priory Hospital Middleton St George I hope that you will be reassured to learn that we have introduced a comprehensive training programme for them. The training provided to date has largely consisted of refresher training. We are in the process of sourcing and arranging more advanced level training as a means of ensuring high levels of expertise among the staff team.” Source location 2014-0518-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure full baseline physical health assessments at admission and increase physical-health complications in ongoing risk assessments.
Verbatim wording from the response “We are taking increasing account of the risks to physical health where there is a co-morbid substance misuse and mental health problems. For example we are ensuring that a full baseline physical health assessment is in place at the point of admission and that potential physical health complications feature more prominently as part of the on-going risk assessment process.” Source location 2014-0518-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate investigation lessons into Priory online training modules.
Verbatim wording from the response “I hope that you will be reassured to learn that the lessons learnt in respect of your investigation into the death of Mr Greenfield will be shared at the forthcoming Priory Group Consultant Psychiatrist Conference which is to be held on Monday 19 January 2014. We will also take the opportunity to integrate the lessons learnt from this tragic incident into our on-line training modules (this is an on-going piece of work however the relevant training modules are all due for review in spring 2015). We will also take the opportunity to raise the matters as part of future safety bulletins and at our internal meetings and conferences for example the lessons learnt from this case were presented at our Medical Directors Meeting which took place on Monday 19 January 2015.” Source location 2014-0518-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an audit of medical staff competencies in specialist detoxification wards.
Verbatim wording from the response “I hope that you will be reassured to learn that we have, in response to Mr Greenfield’s death and your Regulation 28 Report completed an audit of the competencies of the medical staff working in our specialist wards such as those which provide a detoxification service. The audit has been led by the Priory Group Medical Director ████████. Where necessary staff have been transferred to other wards or provided with additional training in the very small number of cases where we have identified individuals who do not have the full suite of competencies that we would expect.” Source location 2014-0518-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer staff or provide additional training where competency gaps are identified.
Verbatim wording from the response “I hope that you will be reassured to learn that we have, in response to Mr Greenfield’s death and your Regulation 28 Report completed an audit of the competencies of the medical staff working in our specialist wards such as those which provide a detoxification service. The audit has been led by the Priory Group Medical Director ████████. Where necessary staff have been transferred to other wards or provided with additional training in the very small number of cases where we have identified individuals who do not have the full suite of competencies that we would expect.” Source location 2014-0518-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a comprehensive training programme for Aspen Ward staff.
Verbatim wording from the response “With regard to the staff at Aspen Ward, Priory Hospital Middleton St George I hope that you will be reassured to learn that we have introduced a comprehensive training programme for them. The training provided to date has largely consisted of refresher training. We are in the process of sourcing and arranging more advanced level training as a means of ensuring high levels of expertise among the staff team.” Source location 2014-0518-Response-by-Priory-Group
Open published response
11 Oct 2014 Mark Hancock · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of a procedure for managing required admissions when no bed is available View source Failure to complete and document patient risk assessments View source Failure to conduct sensitive patient discussions in an appropriate private environment View source Failure to assess the appropriateness of risk management plans View source Failure to schedule outpatient appointments compatibly with patients' existing therapy commitments View source Failure to reassess patients after escalated concerns View source Failure to maintain a complete, accessible multidisciplinary patient record View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mark Hancock · 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
Mark Hancock had a history of severe clinical depression and was receiving treatment at the Priory Hospital. On 12 February 2014, he was found at his parents’ house with serious self-inflicted wounds after concerns about his deteriorating presentation had been escalated but hospital admission did not occur because no bed was available. The report identified concerns about poor or absent records, the lack of a documented risk assessment, insufficient reassessment after concerns were escalated, and the absence of a procedure for admission when no bed was available.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for managing required admissions when no bed is available
Wider context from the report “- There was no procedure or policy in place for staff as to what they should do if a patient requires admission but a bed is not available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and document patient risk assessments
Wider context from the report “- No documented risk assessment was completed in relation to the risk the deceased posed to himself.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct sensitive patient discussions in an appropriate private environment
Wider context from the report “- When concerns were raised in relation to the deceased the further discussions took place in the reception area , an inappropriate environment in which to speak to a patient and obtain important 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the appropriateness of risk management plans
Wider context from the report “- Given there was no formal risk assessment there was no consideration as to whether the risk management plan was appropriate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to schedule outpatient appointments compatibly with patients' existing therapy commitments
Wider context from the report “- The consultant's out-patient appointment with the deceased had been booked to take place in the lunchtime when we was already in a full day therapy session .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess patients after escalated concerns
Wider context from the report “- No further assessment of the deceased was undertaken by the Consultant after concerns had been escalated following his departure from the 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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a complete, accessible multidisciplinary patient record
Wider context from the report “- The quality of the records kept in relation to the deceased was poor and in some circumstances non-existent . No records were kept of the Multi-Disciplinary Team Meetings .
- The Consultant notes were brief and are not kept on the Care Notes system . Such a diverse practice means that there is no overall record of a patient so that all those who have involvement with a patient do not have all relevant, pertinent information available to them .
” Open source report
5 Mar 2014 Neil James Carter · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 6 Failure of staff to accept the authority of the nurse in charge View source Deliberate falsification of nursing records View source Failure to perform basic nursing observations View source Inappropriate ward layout over two floors View source Inadequate staffing numbers and inappropriate staff skill mix View source Failure of management to listen or act on reported issues View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Neil James Carter · 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
Neil James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.
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 Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to accept the authority of the nurse in charge
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority . Management was informed of some issues but failed to listen or act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Deliberate falsification of nursing records
Wider context from the report “(3) There was a deliberate falsification of the nursing record .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure to perform basic nursing observations
Wider context from the report “(1) There were repeated failures to perform basic nursing observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Inappropriate ward layout over two floors
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors . There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing numbers and inappropriate staff skill mix
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Priory Group; that does not assign responsibility.
PFD Monitor interpretation Failure of management to listen or act on reported issues
Wider context from the report “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act .
” 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 monitoring ward staffing levels and skill mixes to ensure they remain appropriate.
Verbatim wording from the response “I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly four-week-cycle Quality Walk Rounds, including checks of patient observations and care plans, with results reviewed through clinical governance.
Verbatim wording from the response “To support compliance, standards across Roehampton Hospital are also monitored internally through the use of Healthcare Division ‘Quality Walk Rounds’ which are undertaken on a weekly basis and operate to a set four-week rolling programme of monitoring. For example, week one involves an assessment of the environment and week two involves an assessment of patient care which includes a review of the completion of patient observations and care plans.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a local Roehampton Human Resources function with trained staff to support staff-management responsibilities.
Verbatim wording from the response “Further, I understand there is now a local Human Resources function at Roehampton Hospital with trained staff who can provide faster support and advice to those with staff management responsibilities who may feel their authority is being challenged.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Priory Healthcare Division Observation and Engagement Policy.
Verbatim wording from the response “We recognise, however, that we should strive to improve compliance with observations and the documentation of those observations in accordance with the risk assessments undertaken. In respect of staff carrying out patient observations, I am informed that these improvements have included changes to the staff induction programme at Roehampton and better registration and monitoring of patients at ward therapy groups. There has also been a review of the overarching Priory Group Healthcare Division Observation and Engagement Policy.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Separate Garden Wing into two wards with dedicated managers, nursing teams, therapists and activity coordinators.
Verbatim wording from the response “I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen supervision and appraisal arrangements to identify and manage authority-related issues more rapidly.
Verbatim wording from the response “You also are concerned that: ‘There was a lack of discipline with staff failing to accept a nurse in charge’s authority’. I understand this arose from the experience of one nurse giving evidence at Mr Carter's inquest, who had found that the individuals had not respected her more senior role. We of course accept that such a situation is unacceptable and whilst there may be differences of opinion between members of staff, I am informed there is now much more emphasis at Roehampton Hospital on there being an effective framework of supervision and appraisals so that the risk of issues in relation to authority can be identified more rapidly and managed.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed daily hospital monitoring visits to wards to check patient care and address immediate staff concerns.
Verbatim wording from the response “You also state that: ‘Management was informed of some issues but failed to listen or act’. In order to facilitate communications between management and staff, I am informed the following are now in place at Roehampton Hospital:” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change the Roehampton staff induction programme to improve compliance with patient observations.
Verbatim wording from the response “We recognise, however, that we should strive to improve compliance with observations and the documentation of those observations in accordance with the risk assessments undertaken. In respect of staff carrying out patient observations, I am informed that these improvements have included changes to the staff induction programme at Roehampton and better registration and monitoring of patients at ward therapy groups. There has also been a review of the overarching Priory Group Healthcare Division Observation and Engagement Policy.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly staff meetings with hospital management to exchange feedback on safety, quality and compliance.
Verbatim wording from the response “You also state that: ‘Management was informed of some issues but failed to listen or act’. In order to facilitate communications between management and staff, I am informed the following are now in place at Roehampton Hospital:” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The two wards are sufficiently staffed and skilled, with separate management and ongoing monitoring of staffing levels and skill mix.
Verbatim wording from the response “I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.” Source location 2014-0103-Response-by-Priory-Group
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations