Recipient

Recipient name withheld

First report 21 Apr 2021•Latest report 21 Apr 2021

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

21 Apr2021
Surrey
Concerns raised10
1. Difficulty accessing community treatment and support after out-of-area placement
2. Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based
3. Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning
1. Discharge from the Home Treatment team on ineffective medication
2. Failure to provide coherent community-care planning and care-coordinator involvement at discharge
3. Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge
4. Lack of policy governing frequency of community review for risk and medication compliance
5. Failure to follow the Care Programme Approach during discharge
6. Premature discharge before the effectiveness of prescribed medication is adequately observed
7. Failure to undertake and record formal pre-discharge risk assessments
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

MARY NABILIA GWANYAMA · 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

Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of 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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Difficulty accessing community treatment and support after out-of-area placement
Wider context from the report
“7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based
Wider context from the report
“4. The informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Mary of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk. The risk assessments were not sufficiently rigorous and evidence based. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning
Wider context from the report
“1. Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan as to what would happen after the Travel Lodge placement ended. There is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Discharge from the Home Treatment team on ineffective medication
Wider context from the report
“6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide coherent community-care planning and care-coordinator involvement at discharge
Wider context from the report
“6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge
Wider context from the report
“2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Lack of policy governing frequency of community review for risk and medication compliance
Wider context from the report
“7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow the Care Programme Approach during discharge
Wider context from the report
“5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Premature discharge before the effectiveness of prescribed medication is adequately observed
Wider context from the report
“5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake and record formal pre-discharge risk assessments
Wider context from the report
“3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised10

Difficulty accessing community treatment and support after out-of-area placement

Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based

Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning

Discharge from the Home Treatment team on ineffective medication

Failure to provide coherent community-care planning and care-coordinator involvement at discharge

Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge

Lack of policy governing frequency of community review for risk and medication compliance

Failure to follow the Care Programme Approach during discharge

Premature discharge before the effectiveness of prescribed medication is adequately observed

Failure to undertake and record formal pre-discharge risk assessments