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First report 8 Nov 2013•Latest report 8 Nov 2013

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. West Yorkshire (West)

    AI-generated summary

    Peter Patrick Adrian Barnes · 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 Patrick Adrian Barnes died from asphyxia caused by hanging in the grounds of Cygnet Hospital, Wyke, while detained under Section 3 of the Mental Health Act 1983. Serious incidents known to nursing staff, including comments about suicide and marks on his neck, were not communicated to the Responsible Clinician, who granted unescorted leave. The report raised concerns about systems for communicating and auditing information and care decisions, involving families in care decisions, and sharing information with police when patients were absent without leave.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication of nursing staff information to Responsible Clinicians

    Wider context from the report

    “(1) The hospital’s systems by which information about patients relating to matters which had been observed by nursing staff - including in particular information about serious incidents - were communicated to the patients’ Responsible Clinician appeared to be inadequate to ensure that such information was full and/or accurate and/or up to date. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a system inviting patients’ families to participate in care decisions

    Wider context from the report

    “(4) There appeared to be no system to ensure that members of patients’ families were invited to be involved in the process by which decisions are made about their care, notwithstanding that they may often be able to impart useful information based upon the patient’s past behaviour, potentially including information about particular matters which might increase or decrease the risk of harm to or self-harm by such 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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate access by staff reporting absent patients to information required by police

    Wider context from the report

    “(5) The hospital’s procedure for responding to patients being absent without leave included reporting such patients to the police as missing persons, but did not appear to be adequate to ensure that members of staff so reporting, or thereafter giving further information, to the police had access to all of the information about the patient which was likely to be required by the police for the purpose of their enquiries. ”
    Open source report

    Source evidence

    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 communicate Responsible Clinician care decisions to nursing staff appropriately and promptly

    Wider context from the report

    “(2) The hospital’s systems by which decisions about patients’ care made by the Responsible Clinician were communicated to nursing staff appeared not to have operated properly and accordingly may be inadequate to ensure that such information about such decisions is communicated in an appropriate and/or timely manner. ”
    Open source report

    Source evidence

    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

    Absence of checking and auditing of clinical information communication systems

    Wider context from the report

    “(3) There appeared to be no system of checking upon or auditing the systems referred to at paragraphs (1) and (2) above to ensure that the Responsible Clinician was receiving full, accurate and up to date information and that nursing staff were receiving appropriate and timely information about the Responsible Clinician’s decisions. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026