Concerns raised 4 Failure of patient safety incident investigators to correctly identify retrospective medical record entries View source Failure to undertake and document mental state examinations and risk assessments before granting ward leave View source Failure to identify and explain retrospective medical record entries View source Failure to maintain sufficiently detailed medical records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Delwyn PREECE · 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
Delwyn Preece, a 64-year-old man, died at Rotherham Hospital on 19 August 2025 from a hypoxic brain injury following deliberate self-suspension by ligature while he was an informal patient at an acute mental health hospital. The principal concerns were repeated granting of leave without documented mental state examinations or risk assessments, poor and retrospective record-keeping, and shortcomings in the patient safety investigation arising from unfamiliarity with the medical records system.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of patient safety incident investigators to correctly identify retrospective medical record entries
Wider context from the report “3. The Patient Safety Incident Investigation authors were unfamiliar with the medical records system which lead to the retrospective entries not being identified correctly , therefore the investigation did not make any finding. However, with more understanding, it is likely the retrospective entries in the medical records who have been identified and their relevance realised which would have altered the content and findings of the report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and document mental state examinations and risk assessments before granting ward leave
Wider context from the report “1. There were consistent and repeated incidents (13 incidents in 6 days) where leave from the ward was granted without any documented mental state examination or risk assessment being undertaken prior to the patient being permitted to leave the ward .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and explain retrospective medical record entries
Wider context from the report “2. There was poor documentation throughout the medical records with entries lacking detail, being added retrospectively (up to two days later) without any explanation or referencing the retrospective nature of the entry .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficiently detailed medical records
Wider context from the report “2. There was poor documentation throughout the medical records with entries lacking detail , being added retrospectively (up to two days later) without any explanation or referencing the retrospective nature of the entry.
” Open source report
Concerns raised 2 Lack of crisis support and specialist assessment access for patients over 65 View source Failure to provide crisis-service information that accurately reflects age eligibility View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carol Ann Guest · 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
Carol Ann Guest died by suicide after hanging herself at home on 24 March 2024, before a planned consultant visit could be arranged following an urgent mental health referral. The principal concerns were inadequate crisis support for patients over 65, delays in sending and responding to the urgent referral, and the provision of a crisis number that was not available to people over 65.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of crisis support and specialist assessment access for patients over 65
Wider context from the report “During the course of the evidence from both family and medical witnesses it became clear that there were no adequate systems in place for providing crisis support to patients over the age of 65 . The family were very concerned and very frustrated by the futile attempts they made to secure psychiatric input and support when they could see a rapidly deteriorating picture. There was no explanation as to why individuals in crisis who were 65 or under had access to the crisis service but once a person is over 65 that service is no longer available to them . It is not clear whether access to such services would have altered the outcome but the current structure and services available in my view denied Ms Guest with the opportunity of obtaining specialist assessment support at a much earlier stage . A further concern was that the GP surgery provides patients with the crisis number seemingly without appreciating that this would only be available to those who were 65 or under. Furthermore, the family's evidence was that when they called 101 seeking medical input and support for Ms Guest, they were told they would be referred to the crisis team but as soon as Ms Guest's age was mentioned they halted that process and said that they would not be able to refer her after all because of her age .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide crisis-service information that accurately reflects age eligibility
Wider context from the report “During the course of the evidence from both family and medical witnesses it became clear that there were no adequate systems in place for providing crisis support to patients over the age of 65. The family were very concerned and very frustrated by the futile attempts they made to secure psychiatric input and support when they could see a rapidly deteriorating picture. There was no explanation as to why individuals in crisis who were 65 or under had access to the crisis service but once a person is over 65 that service is no longer available to them. It is not clear whether access to such services would have altered the outcome but the current structure and services available in my view denied Ms Guest with the opportunity of obtaining specialist assessment support at a much earlier stage. A further concern was that the GP surgery provides patients with the crisis number seemingly without appreciating that this would only be available to those who were 65 or under . Furthermore, the family's evidence was that when they called 101 seeking medical input and support for Ms Guest, they were told they would be referred to the crisis team but as soon as Ms Guest's age was mentioned they halted that process and said that they would not be able to refer her after all because of her age.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with clinical audit to consider evaluating older adults’ access to crisis presentations in the 2025/26 audit programme.
Verbatim wording from the response “• The Trust’s Equity and Inclusion Group, which I chair, is already auditing the work to replace age-specific policies in our pathways. We will work with clinical audit to consider how best, in our 2025/26 programme of audit, evaluation of access for crisis presentations in older adults. This should help us to have a better picture of patterns of demand, through which to further refine services.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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 Issue a written operating protocol requiring crisis referrals for older people to be accepted and assessed regardless of age or time of day.
Verbatim wording from the response “We have found that our arrangements for accepting crisis referrals for older people are inconsistent within RDaSH, and do not benefit from agreed written protocols. This will change with issue of a new operating protocol to those working clinically on November 7th 2024 – effective immediately.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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 Disseminate revised crisis pathways, referral routes and advice arrangements to staff, primary care, NHS111, communities, carers and patients.
Verbatim wording from the response “We will set out our revised arrangements in writing for those providing the services, but also for local GPs. We will also ensure that, during November, relevant primary care leadership meetings are advised of the changes. That is because we suspect that, over a period of years, pathway changes have been made, and practices have varied knowledge of them. The arrangements will also be clarified in our triage-SPA and to NHS111. This work will be complete before the end of November. In putting this change into place, we will also clarify for local practices, the best routes through which themselves to seek advice, and how to make referrals including urgent referrals. Importantly this will be shared with our communities, carers and patients through all our communication channels.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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 the revised crisis and community mental health arrangements in local team induction.
Verbatim wording from the response “• Induction arrangements for our local crisis teams, and wider community mental health teams, take account of what is described in this letter. This month the Trust introduced new induction arrangements across the organisation, with a dedicated day for in-team local induction complimented by a much more in-depth institutional induction, taking place in our communities.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
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 Roll out DIALOG/DIALOG+ to replace the Care Programme Approach and support outcome-focused care planning across services.
Verbatim wording from the response “Through 2025/26, the Trust is introducing DIALOG/DIALOG+ into our services and replacing the Care Programme Approach (CPA). The intention of this change, adopted by some other mental health providers nationally, is to better support patients and their carers, with plans of care that are outcome focused. Introducing DIALOG should help us too to have a more accessible” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove age-based access barriers from mental health services through revised service arrangements and additional staff training.
Verbatim wording from the response “Local service specifications from commissioning bodies do appear to create age-based parameters for who can access which services. The Trust committed earlier in 2024/25 to remove such externally directed barriers to our services, both for children and young people, and older adults. We are working to a programme to do this by spring 2025, as the changes involved require us to provide additional training to staff in different presentations and techniques. To be clear, services will still have specialists focusing on particular conditions, but the distinctions between teams will not be driven by age-parameters.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A compelling case for creating dedicated older people’s crisis services has not been identified, so existing teams should improve their response instead.
Verbatim wording from the response “There is some evidence that dedicated older peoples’ crisis services have merit. Whilst we will keep the introduction of such services under review, we have not found a compelling case to create such services and, to do so, would require significant investment from the Integrated Care Board locally. We consider it unlikely that this will occur over the next two years, and as such it is important our existing teams are better able to respond to needs among all adults.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Crisis provision was not considered a relevant factor in what happened; missed referrals to the established older people’s community team were the issue.
Verbatim wording from the response “I should be direct that we do not believe that crisis provision was a relevant factor in what happened to Carol. It is apparent from the attached case summary from ████████ that there were missed opportunities to refer her to the established older peoples’ community team. Having received a referral on March 15th, an appointment was expedited to take place on March 26th. Carol was unaware of both the referral (not issued to her, and the appointment, owing to her death). It is deeply regrettable that relatives who cared for Carol may have been left, in evidence before you, with the impression that crisis services were a primary cause of harm. We will be seeking to meet with family members to hear from them and to share our conclusions with them.” Source location Response from Rotherham Doncaster and South Humber NHS Foundation Trust
Open published response
Concerns raised 2 Failure to maintain random drug testing for people not resident at a Probation Hostel View source Failure to share relevant information with the Probation Service after identifying details become available 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 John Gogarty · 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 John Gogarty was unlawfully killed at his home on 13 July 2015 by two people who planned to steal money to pay a drug debt; he was stabbed 69 times. The report identified missed opportunities and inadequate monitoring by the Probation Service, including failures relating to licence breaches, drug testing and recall. It also identified a missed opportunity for information about an offender’s relationship with a female patient to be shared with the Probation Service.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain random drug testing for people not resident at a Probation Hostel
Wider context from the report “The evidence showed that there was appropriate random drug testing for ████████ whilst he was resident at the Probation Hostel. However, when he left the hostel there was no system in place for random testing . This, in the view of the court, was a relevant issue.
It is accepted that the evidence further showed that there is now a system in place for random testing of those not resident at a Probation Hostel . However, the purpose of this Regulation 28 report is to underline the courts view of the importance of such testing. Should a time come in the future when the operation of random testing becomes more difficult, whether through financial restraint or otherwise, the court will be concerned if random testing was stopped .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information with the Probation Service after identifying details become available
Wider context from the report “Your Trust was solely concerned with the care of ████████. During that care your patient was associating with who had a very considerable history and was under the supervision of the National Probation Service following a sentence for murder. Although original offers were made to contact the Probation Service to pass on information, these came to nothing because insufficient details about the male were known. However, within a relatively short time further information to identify this male became apparent but there was no further follow up with the Probation Service.
No specific criticism is made of the member of staff involved at that time, it might very well be that many staff might have assumed that there was nothing to be gained. However, in reality, if the Probation Service had been aware of your patients background they would have at least had the opportunity to consider the conditions of the parole afresh, potentially putting in place further safeguards.
It is respectfully suggested that the lesson here is that small pieces of information properly shared on an inter-agency basis might well add up to a bigger picture for other organisations.
” Open source report
Concerns raised 1 Ineffective communication about significant pain levels between nurses and the general practitioner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jane Bullock Wilson Stables · 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
Jane Bullock Wilson Stables had severe rheumatoid arthritis, was bed bound and experienced poorly controlled pain and pressure sores. Concerns included ineffective communication between nurses and the general practitioner about her pain, and failure to follow the care plan for regular repositioning, with pressure sores significantly deteriorating before her admission to hospital, where she died.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication about significant pain levels between nurses and the general practitioner
Wider context from the report “(1) Ineffective communication between the nurses and general practitioner regarding ongoing significant pain levels which were impeding care 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 Consider direct professional dialogue about pain management when treatment is not optimised, regardless of patient or carer communication channels.
Verbatim wording from the response “A full and frank discussion took place at this meeting. It was both professional and cordial. I produced the summary of the learning from that event with some actions. It included the need to consider a direct dialogue between professionals (including the GP) in relation to pain management if this was not optimised regardless of whether patients and/or carers maintained their own communication channels with pain management professionals.” Source location 2016-0457-Response-by-RDASH
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 Convene a multidisciplinary meeting and produce a documented summary of learning and actions.
Verbatim wording from the response “In relation to points one and two from my communication of 8 February, a meeting was held on 24 February 2017 between myself and the relevant District Nurses and their Line Managers. I chaired this meeting. I provided the attendees with a summary of my understanding of the case regarding Regulation 28 report. The participants were given the opportunity of reading this summary. They had already been sent a copy of your Regulation 28 report in advance.” Source location 2016-0457-Response-by-RDASH
Open published response
Concerns raised 3 Failure of the IAPT risk assessment tool to record less threatening levels of risk and deterioration over time View source Lack of universal recognition among mental health practitioners of suicide risk patterns in middle-aged males and socio-economic factors View source Insufficient written narrative detail accompanying coded clinical record entries View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Derek Vaughan · 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
Jason Derek Vaughan died by suicide by hanging at his home on 23 September 2015. The principal concerns were limitations in the IAPT electronic clinical records, a risk assessment tool that did not capture deterioration below its highest-risk level, and insufficient recognition of factors associated with suicide among middle-aged men and socio-economic groups.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the IAPT risk assessment tool to record less threatening levels of risk and deterioration over time
Wider context from the report “(2) The existing IAPT risk assessment tool utilises a numerical rating system which has, as its starting level 1, “things feel so bad that you think about killing yourself”, and which does not allow for the recording of a less threatening position , thereby not providing a means of reflecting a deterioration, is a patient's state of risk, over time, to the current Level 1 status .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of universal recognition among mental health practitioners of suicide risk patterns in middle-aged males and socio-economic factors
Wider context from the report “(3) It may not be universally recognised by all mental health practitioners , that the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2015) has identified an increasing number of suicides amongst middle aged males and also socio-economic factors becoming increasingly common in suicides .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient written narrative detail accompanying coded clinical record entries
Wider context from the report “(1) The effectiveness of the IAPT electronic patient clinical records system (SystemOne) may be limited, in some instances, by there being insufficient written narrative detail (eg. As to medication commencement dates, doses, changes etc.) to accompany the coded data entries in the drop down box selection
” 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 Deliver three workshops for IAPT teams on findings from the Confidential Inquiry into Suicides and Homicides.
Verbatim wording from the response “3. It may not be universally recognised by all mental health practitioners, that the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2015) has identified an increasing number of suicides amongst middle aged males and also socio-economic factors becoming increasingly common in such suicides.” Source location 2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
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 Develop and disseminate a newsletter and Trust-wide communications message summarising suicide risk factors, including risks affecting middle-aged men.
Verbatim wording from the response “In addition we have continued our overall Trust Education Programme by developing a newsletter which will go out to all mental health practitioners within the organisation summarising some of the risk factors involved in completed suicide. I have enclosed this for your information as it focuses on the issue of suicide in middle aged men. In addition this will be noted in an email that is sent from our Communications Department to all practitioners within the Trust.” Source location 2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing IAPT risk-assessment system is considered sufficient, so the service decided not to adopt the alternative Columbia scale.
Verbatim wording from the response “The action plan highlights how the IAPT service continually appraises the effectiveness of any tools it might use. In this case the Service Managers have been actively considering an alternative tool called the ‘Columbia Suicide Severity Rating Scale’. After proper deliberation the services have elected not to use this tool because they do not believe it would offer improvements compared with the current system. Again for the avoidance of doubt, I wish to emphasise that any tool used would simply add value to robust clinical decision making based on data from a number of sources including clinical interview. We would never manage risk solely based on any tool regardless of how effective it was deemed to have been in research studies.” Source location 2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The SystmOne system does not have a systemic defect preventing staff from recording important medication-management information.
Verbatim wording from the response “Electronic systems can support adequate record keeping but ultimately it still depends upon a staff member to input data. In your Regulation 28 report you gave examples regarding medications management. Recording adequate data regarding medication management is absolutely key in healthcare. This is because it is an essential part of the management of the majority of patients with severe mental disorder, and often plays a part in those with less severe mental health conditions. All medications have side effects, some of them serious. It is for this reason that I would agree with you wholeheartedly that recording adequate data regarding medications management is essential. However there does not appear to be a systemic issue with the SystmOne tool which prevents the recording of invaluable data.” Source location 2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identifying middle-aged male status alone is considered insufficient to translate into a suicide-prevention intervention without other risk factors.
Verbatim wording from the response “Although suicide is a terrible and tragic event, it is still relatively uncommon when one considers the prevalence of mental health disorder in our communities. In the scenario you asked us to focus on, namely the increased risk of suicide in middle aged men, we treat many individuals who would fall into this category. Very few of them indeed will go on to commit suicide, thank goodness. Consequently, simply identifying this factor alone would be difficult to translate into a suicide prevention act. However, this factor, along with other risk factors (e.g. substance misuse, recent life event, chronic pain condition etc) would focus practitioners on taking a particular interest in a person’s history to ensure that adequate assessment occurred.” Source location 2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Open published response
Concerns raised 4 Inadequacy of guidance incorporating the ethos and workings of the early discharge plan View source Variable staff knowledge and understanding of the early discharge pathway View source Lack of effective auditing of communication systems View source Failure to routinely follow communication systems between families and carers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James Savo · 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 Savo had a longstanding history of depression and died by hanging on 3 December 2013, four days after discharge from inpatient treatment. The concerns identified were insufficient communication with family and carers, inadequate consideration of family concerns and the timing of home-treatment input during discharge planning, and variable understanding and possible inadequacy of the early discharge pathway. The report also identified a lack of effective auditing to ensure communication systems were followed.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of guidance incorporating the ethos and workings of the early discharge plan
Wider context from the report “(2) The early discharge plan was described as a mechanism to try and ensure a seamless transition from inpatient care to community based care in appropriate cases. Whilst this is clearly a system adopted locally and currently being re-evaluated, given it's significance in facilitating smooth transitions at a time which was recognised as being difficult for many patients returning to the community, consideration should be given as to whether the current guidance etc adequately incorporates the ethos and workings of the early discharge plan . Witnesses knowledge and understanding of this pathway was variable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Variable staff knowledge and understanding of the early discharge pathway
Wider context from the report “(2) The early discharge plan was described as a mechanism to try and ensure a seamless transition from inpatient care to community based care in appropriate cases. Whilst this is clearly a system adopted locally and currently being re-evaluated, given it's significance in facilitating smooth transitions at a time which was recognised as being difficult for many patients returning to the community, consideration should be given as to whether the current guidance etc adequately incorporates the ethos and workings of the early discharge plan. Witnesses knowledge and understanding of this pathway was variable .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective auditing of communication systems
Wider context from the report “(1) The systems described as being in place which should be followed to ensure effective communication between families/carers appear not to be routinely followed. As this communication is an integral part of a patient's management and future treatment plans it is essential that all staff are aware of the communication, the nature of it and who has primary responsibility for ensuring that it takes place. Furthermore, there is no evidence of any effective auditing process to ensure such systems are being 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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely follow communication systems between families and carers
Wider context from the report “(1) The systems described as being in place which should be followed to ensure effective communication between families/carers appear not to be routinely followed . As this communication is an integral part of a patient's management and future treatment plans it is essential that all staff are aware of the communication, the nature of it and who has primary responsibility for ensuring that it takes place. Furthermore, there is no evidence of any effective auditing process to ensure such systems are being followed.
” Open source report
Concerns raised 4 Absence of clear guidance for checking patients and rooms for potential self-harm items View source Inadequate staff training for record keeping and communication View source Absence of a single accessible reference sheet summarising key patient safety information View source Imbalance between holistic care and patient safety View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
DANIEL WILLIAMS · 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
Daniel Williams, who had psychiatric problems following a diagnosis of diabetes and was admitted to hospital after an insulin overdose, died by hanging in his hospital room on 15 June 2013. The concerns included inadequate staff training, record keeping and communication; insufficient exploration of suicidal thoughts and intent; unclear guidance on checking rooms and patients for potential self-harm items; and the absence of a single summary of key risks and incidents in the notes.
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 Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of clear guidance for checking patients and rooms for potential self-harm items
Wider context from the report “(3) The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training for record keeping and communication
Wider context from the report “(1) Quality of staff training , particularly with regard to record keeping and communication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a single accessible reference sheet summarising key patient safety information
Wider context from the report “(4) The absence of a single reference sheet in the notes summarising key issues, risk factors, significant incidents and concerns readily accessible to all involved in patient care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rotherham Doncaster and South Humber NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Imbalance between holistic care and patient safety
Wider context from the report “(2) The emphasis on taking a holistic approach to care and whether there is an imbalance between adopting such an approach and patient safety .
” 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