Royal College of PsychiatristsIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 3 Mar 2014•Latest report 19 Sep 2025

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
26

Naming this recipient

Published responses
42%

Found for named reports

Concerns addressed
22

Across all linked responses

Stated actions
43

Described in responses

Concerns and recipient responses

Statements from Royal College of Psychiatrists linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Kirabo Kiwanuka · 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

    Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

    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 Royal College of Psychiatrists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about the appropriate care setting and staffing model for physically ill psychiatric patients

    Wider context from the report

    “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit. She was not examined by a physician when she developed abnormal vital signs. At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of 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 Royal College of Psychiatrists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of agreement about when physician referral or senior medical review is required

    Wider context from the report

    “1. There is lack of senior professional agreement about the criteria needed for diagnosis of NMS, or the need for referral to physicians, even in retrospect Doctors did not agree whether atypical NMS exists and whether in the absence of rigidity cases should be managed differently. In particular a psychiatrist considered psychiatrists were better at care of NMS in their ITU, despite there not being facilities for cardiac monitoring or frequent blood gas analysis, as recommended by the expert psychiatrist, whilst my expert physician simply did not think she needed intensive medical care. There was even disagreement whether a medical registrar opinion or consultant was required. How are junior staff to know what is optimal 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 Royal College of Psychiatrists; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of timely physician assessment for acutely ill psychiatric-facility patients

    Wider context from the report

    “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit. She was not examined by a physician when she developed abnormal vital signs. At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of 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 Royal College of Psychiatrists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of senior professional agreement about NMS diagnostic criteria

    Wider context from the report

    “1. There is lack of senior professional agreement about the criteria needed for diagnosis of NMS, or the need for referral to physicians, even in retrospect Doctors did not agree whether atypical NMS exists and whether in the absence of rigidity cases should be managed differently. In particular a psychiatrist considered psychiatrists were better at care of NMS in their ITU, despite there not being facilities for cardiac monitoring or frequent blood gas analysis, as recommended by the expert psychiatrist, whilst my expert physician simply did not think she needed intensive medical care. There was even disagreement whether a medical registrar opinion or consultant was required. How are junior staff to know what is optimal 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 Royal College of Psychiatrists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to involve family in best-interests decisions for sectioned patients lacking capacity

    Wider context from the report

    “3. Where a patient lacks capacity and is under section, the involvement of the family in determining her best interests is required but here it was limited and yet they had concerns about the risks of treatment. The parents were not given the opportunity to contribute their views to the decision to administer Acuphase, but decisions had to be taken in situations of acute disturbance. What is the role of each of psychiatrists, physicians and next of kin in reaching critical care decisions for sectioned patients with acute medical and psychiatric problems? ”
    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