Concerns raised 3 Lack of full assessment after abrupt medication cessation View source Risk of relapse and serious mental-health deterioration following abrupt medication cessation View source Failure to monitor patients after abrupt medication cessation 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
Jason Ricardo White · 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 Ricardo White died on 10 December 2024; the cause of death is redacted in the supplied text, and the inquest conclusion was suicide. The principal concerns were the abrupt cessation of olanzapine, failure to follow the planned daily monitoring, and the resulting risk of relapse and serious deterioration in mental health.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of full assessment after abrupt medication cessation
Wider context from the report “1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed.
2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health.
3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of relapse and serious mental-health deterioration following abrupt medication cessation
Wider context from the report “1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed.
2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health.
3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients after abrupt medication cessation
Wider context from the report “1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed .
2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health.
3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored ; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health.
” 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 Standardise formal logging, multidisciplinary review, risk-based monitoring decisions, named clinical ownership and contingency recording after antipsychotic medication changes across all relevant services.
Verbatim wording from the response “As a direct response to the learning from this case, we have strengthened our approach to monitoring service users following changes to antipsychotic medication. These improvements are already being implemented in practice, with full standardisation across all relevant services to be completed by 1 March 2026.” Source location 2025-0638 - Response from Sheffield Health Partnership University NHS Foundation Trust
Open published response
Concerns raised 7 Failure of referral communication channels to provide reliable access and confirmation View source Delays in triaging and progressing referrals for mental health care View source Failure to communicate clinically relevant information between services about epilepsy and psychosis View source Failure to send discharge summaries to the General Practitioner View source Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation View source Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication View source Inappropriate rejection of referrals despite evidence of psychosis View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bryan Andrews and Mary Andrews · 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
Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of referral communication channels to provide reliable access and confirmation
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in triaging and progressing referrals for mental health care
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clinically relevant information between services about epilepsy and psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to send discharge summaries to the General Practitioner
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out consultant review of antipsychotic medication alongside epilepsy medication
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate rejection of referrals despite evidence of psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” 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 Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
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 Include discharge summaries in annual service record-keeping audits to verify timely transmission to GPs and required quality standards.
Verbatim wording from the response “2. Discharge summaries are electronically sent to GPs through our electronic patient record system. In this case, although the discharge summary was created on 9 May 2022, the day of discharge, it was further edited on 13 May 2022. It appears that because the discharge” Source location Response from Sheffield Health and Social Care
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 further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
Open published response
Concerns raised 5 Failure to keep accurate and complete records of interactions View source Failure to ensure consistent review of medical notes before appointments, assessments, and handovers View source Failure of discharge reports to provide sufficient diagnostic and risk-trigger information for accurate handover View source Lack of an audit system to check records View source Failure to routinely check and update risk assessments View source See 2 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
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Develop a Standard Operating Procedure specifying how to prepare for clinical reviews, appointments and handovers, including required documentation review.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Complete and launch a new electronic discharge template, supported by local best-practice training.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Include accurate, complete medical discharge-summary requirements in the medical staff rotation training programme.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Complete and audit discharge-summary and safety-netting practice, and review existing discharge templates.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Complete and roll out a Trustwide clinical record-keeping policy and associated staff training.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Implement the new electronic record system to deliver automated record-keeping improvements.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Issue a Blue Light Learning Notice and cascade the requirement for timely, accurate recording of patient-facing interactions to clinical teams.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Continue reinforcing risk-assessment review and updating through supervision, and monitor compliance through clinical and record-keeping audits.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023. View source
Action
Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Disseminate the clinical-review preparation procedure to relevant clinical staff through governance, supervision, training and the intranet.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Review the format and function of discharge summaries to include early warning signs of deterioration.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Assess the feasibility of extending live risk-document dashboards to other services.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023. View source
Action
Use live community-team dashboards to identify when key documents require review, revision or updating.
Stated completedThe respondent said that this action was complete when they made their response on 12 December 2023. View source
Action
Scope development of a new clinical risk-assessment tool within the electronic patient record programme.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023. View source
Action
Implement a clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.
Stated completedThe respondent said that this action was complete when they made their response on 12 December 2023. View source
Action
Incorporate the revised discharge-summary format into the new Rio electronic patient record system.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Instruct inpatient Responsible Clinicians to record diagnoses in Insight for inclusion in discharge summaries.
Stated completedThe respondent said that this action was complete when they made their response on 12 December 2023. View source
Action
Roll out the clinical record keeping training package across the Trust following its development and pilot session.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023. View source
Action
Audit clinical record keeping, including risk assessments and discharge summaries.
Stated completedThe respondent said that this action was complete when they made their response on 12 December 2023. View source
Action
Conduct biannual Trust-wide audits of compliance with risk-assessment requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 12 December 2023. View source
Action
Disseminate and publish a staff alert reminding all staff about good-quality record keeping.
Stated completedThe respondent said that this action was complete when they made their response on 12 December 2023. View source See 20 more actions
×
AI-generated summary
Gareth Michael Etchells-Heights · 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
Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate and complete records of interactions
Wider context from the report “4. Record Keeping
There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth . There is no audit system in place to check the records.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent review of medical notes before appointments, assessments, and handovers
Wider context from the report “2. Review of the medical notes
There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge reports to provide sufficient diagnostic and risk-trigger information for accurate handover
Wider context from the report “1. Discharge and safety netting
The discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers. The information within the discharge report was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an audit system to check records
Wider context from the report “4. Record Keeping
There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check and update risk assessments
Wider context from the report “3. Failure to update risk assessment
There was a failure to update Gareth’s risk assessment , which at the date of his death was last updated on 7 April 2022. Gareth’s psychotic state had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments .
” 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 Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Verbatim wording from the response “The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team. An audit of quality compliance will be incorporated into the existing cycle of biannual record keeping audits. Results from the audits will be reflected and acted through our local ward governance processes.” Source location Response from Sheffield Health and Social Care
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 Develop a Standard Operating Procedure specifying how to prepare for clinical reviews, appointments and handovers, including required documentation review.
Verbatim wording from the response “There is no established local guidance on how to prepare for a clinical review, appointment or handover with practice by and is largely being guided by local custom and practice and training. The Directorate Leadership Team will develop a Standard Operating Procedure covering ‘how to prepare for a clinical review’ which will include what documentation should be read as part of the preparation for this by 30 April 2024.” Source location Response from Sheffield Health and Social Care
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 and launch a new electronic discharge template, supported by local best-practice training.
Verbatim wording from the response “We will complete and audit existing practice in relation to the completion of our discharge summaries and the process and documentation in support of safety netting. We will also review the format and function of our existing discharge templates. These tasks will be completed by the end of February 2024. Any deficiencies identified through these reviews and audits will be used to improve the discharge template in our new Electronic Patient Record System (RIO) and discharge planning practice in our clinical teams.” Source location Response from Sheffield Health and Social Care
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 Include accurate, complete medical discharge-summary requirements in the medical staff rotation training programme.
Verbatim wording from the response “The importance of accurate and full completion of the medical discharge summaries will be included in the rotation training programme for medical staff.” Source location Response from Sheffield Health and Social Care
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 and audit discharge-summary and safety-netting practice, and review existing discharge templates.
Verbatim wording from the response “We will complete and audit existing practice in relation to the completion of our discharge summaries and the process and documentation in support of safety netting. We will also review the format and function of our existing discharge templates. These tasks will be completed by the end of February 2024. Any deficiencies identified through these reviews and audits will be used to improve the discharge template in our new Electronic Patient Record System (RIO) and discharge planning practice in our clinical teams.” Source location Response from Sheffield Health and Social Care
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 and roll out a Trustwide clinical record-keeping policy and associated staff training.
Verbatim wording from the response “In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.” Source location Response from Sheffield Health and Social Care
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 Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
Verbatim wording from the response “In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.” Source location Response from Sheffield Health and Social Care
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 the new electronic record system to deliver automated record-keeping improvements.
Verbatim wording from the response “I will refer back to my letter dated 3 November 2023 where we outlined the move to our new record system (RIO). The implementation of the system has been delayed for some services in the Trust, however, the functionality of RIO will bring about significant automated improvements in record keeping.” Source location Response from Sheffield Health and Social Care
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 a Blue Light Learning Notice and cascade the requirement for timely, accurate recording of patient-facing interactions to clinical teams.
Verbatim wording from the response “In the meantime, we will issue a Blue Light Learning Notice to all clinical teams and flag through our Trustwide cascade with the Executive Team the need to record accurately all patient facing interactions in a timely manner.” Source location Response from Sheffield Health and Social Care
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 reinforcing risk-assessment review and updating through supervision, and monitor compliance through clinical and record-keeping audits.
Verbatim wording from the response “Our training currently focuses on the importance of reviewing and updating risk assessments, we will continue to deliver these key messages through supervision and monitor through clinical audit, recognising that clinical audit is a snapshot of overall caseloads. Audit will also take place through individual clinical supervision at team level as part of the record keeping requirements.” Source location Response from Sheffield Health and Social Care
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 Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
Verbatim wording from the response “We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.” Source location Response from Sheffield Health and Social Care
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 the clinical-review preparation procedure to relevant clinical staff through governance, supervision, training and the intranet.
Verbatim wording from the response “On completion, the guide will be disseminated through local governance structures, via supervision and training arrangements to all clinical staff who utilise our electronic patient records and be available on our intranet.” Source location Response from Sheffield Health and Social Care
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 format and function of discharge summaries to include early warning signs of deterioration.
Verbatim wording from the response “The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary. Discussions have taken place regarding the purpose of discharge summaries and the misunderstanding of their use. We commissioned 360 Assurance, our internal auditors, to undertake an audit of our clinical record keeping, including risk assessments and discharge summaries. This audit was completed in May 2024. From the findings of the audit and the new national guidance that was issued in January 2024, we have agreed to review the format and function of our discharge summaries to include early warning signs of deterioration.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Assess the feasibility of extending live risk-document dashboards to other services.
Verbatim wording from the response “Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Use live community-team dashboards to identify when key documents require review, revision or updating.
Verbatim wording from the response “Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Scope development of a new clinical risk-assessment tool within the electronic patient record programme.
Verbatim wording from the response “In addition, as part of the new electronic patient record development, key clinical leaders will be scoping the development of a new clinical risk assessment tool.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.
Verbatim wording from the response “We developed a clinical record keeping standards policy earlier this year to provide clarity on the expected requirements to ensure high quality, person centred clinical documentation across the Trust. Incorporated within this is a section to guide clinicians around preparing for service user appointments, ensuring they are briefed on the current issues, risks and concerns. It is accepted that this will depend upon the relationship between the service user and their worker. This will enable staff to have an up-to-date understanding of the service user’s condition and mental state.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Incorporate the revised discharge-summary format into the new Rio electronic patient record system.
Verbatim wording from the response “The revised format will be incorporated as we rollout our new electronic patient record system (Rio) in late 2024/early 2025.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Instruct inpatient Responsible Clinicians to record diagnoses in Insight for inclusion in discharge summaries.
Verbatim wording from the response “The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary. Discussions have taken place regarding the purpose of discharge summaries and the misunderstanding of their use. We commissioned 360 Assurance, our internal auditors, to undertake an audit of our clinical record keeping, including risk assessments and discharge summaries. This audit was completed in May 2024. From the findings of the audit and the new national guidance that was issued in January 2024, we have agreed to review the format and function of our discharge summaries to include early warning signs of deterioration.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 Roll out the clinical record keeping training package across the Trust following its development and pilot session.
Verbatim wording from the response “Following the publication of the new clinical record keeping standards policy, a new training package has been developed to support the implementation of the policy and a pilot training session has already taken place with preceptee nurses. The feedback from this pilot session has been extremely positive. The training is now being rolled out across the Trust by the Clinical Risk and Patient Safety Advisor.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 clinical record keeping, including risk assessments and discharge summaries.
Verbatim wording from the response “The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary. Discussions have taken place regarding the purpose of discharge summaries and the misunderstanding of their use. We commissioned 360 Assurance, our internal auditors, to undertake an audit of our clinical record keeping, including risk assessments and discharge summaries. This audit was completed in May 2024. From the findings of the audit and the new national guidance that was issued in January 2024, we have agreed to review the format and function of our discharge summaries to include early warning signs of deterioration.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 biannual Trust-wide audits of compliance with risk-assessment requirements.
Verbatim wording from the response “Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
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 and publish a staff alert reminding all staff about good-quality record keeping.
Verbatim wording from the response “All staff have been reminded about the importance of good quality record keeping through an alert cascade that was produced, disseminated and published on the staff intranet.” Source location 2023-0517 Response from Sheffield Health and Social Care - Update
Open published response
Concerns raised 5 Lack of risk assessments supporting adequate communication with the patient View source Failure to regard identified family members at risk of harm as members of the public for s41 Order purposes View source Overreliance on family members to advocate for the patient View source Failure to incorporate relevant clinical evidence into discharge decisions View source Failure to integrate Criminal Justice recommendations with work undertaken at St Andrew's View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marjorie Grayson · 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
Marjorie Grayson died by suicide on 3 September 2020 after falling from a first-floor bedroom window at her home. The report identified concerns about the use of a hospital order without additional restrictions, inadequate consideration of the seriousness of her previous offence and impulse-control risks, limited face-to-face contact after discharge during the Covid-19 pandemic, and insufficient support and communication for her family.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessments supporting adequate communication with the patient
Wider context from the report “7. Sheffield Health and Social Care Trust did not have risk assessments which supported adequate communication with Mrs Grayson herself and instead placed an overburden on her family to advocate for her
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to regard identified family members at risk of harm as members of the public for s41 Order purposes
Wider context from the report “4. I am unclear why members of Mrs Grayson's family, who do not reside with her ordinarily and at the time of her offending, are not regarded as members of the public for the purposes of a s41 Order . The risk of harm to them was clear in the mind of the author and had they been regarded as members of the public this may have led to a s41 Order being made which, although potentially making no difference in this case, may do so in 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Overreliance on family members to advocate for the patient
Wider context from the report “7. Sheffield Health and Social Care Trust did not have risk assessments which supported adequate communication with Mrs Grayson herself and instead placed an overburden on her family to advocate for her
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate relevant clinical evidence into discharge decisions
Wider context from the report “5. Sheffield Health and Social Care Trust determined to do with Mrs Grayson upon discharge did not pay sufficient heed to the clinical evidence obtained by the Ministry of Justice and which was reflected in the practice at St Andrew's.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate Criminal Justice recommendations with work undertaken at St Andrew's
Wider context from the report “6. Sheffield Health and Social Care Trust do not seem to have joined up the actions that were recommended from the Criminal Justice proceedings and the work undertaken at St Andrew's resulting in a discharge which did not adequately reflect the risks to and from Mrs Grayson.
” 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 Communicate with service users and families, including families in care planning, to establish a shared understanding of risk management.
Verbatim wording from the response “Communication must take place with both service user and their families and where families are included in planning care. | Clinical Psychologist, Acute and Community Directorate | End of August 2022 | The service user, the family and the clinical team have a shared understanding of how risks are being managed.
Ensure that complex clinical decisions take into account the full risks that they are multidisciplinary, include the service user and family view and are clearly recorded. | Clinical Director / Head of Service / Head of Nursing for Acute and Community Directorate | End of July 2022 | The service user, the family and the clinical team have a shared understanding of how risks are being managed.
Deliver online training session to staff in older adult MHTs on forensic sections of the Mental Health Act.” Source location Response from NHS Sheffield Health and Social Care
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 complex clinical decisions consider multidisciplinary risk information and service-user and family views, with decisions clearly recorded.
Verbatim wording from the response “Communication must take place with both service user and their families and where families are included in planning care. | Clinical Psychologist, Acute and Community Directorate | End of August 2022 | The service user, the family and the clinical team have a shared understanding of how risks are being managed.
Ensure that complex clinical decisions take into account the full risks that they are multidisciplinary, include the service user and family view and are clearly recorded. | Clinical Director / Head of Service / Head of Nursing for Acute and Community Directorate | End of July 2022 | The service user, the family and the clinical team have a shared understanding of how risks are being managed.
Deliver online training session to staff in older adult MHTs on forensic sections of the Mental Health Act.” Source location Response from NHS Sheffield Health and Social Care
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 thorough risk assessments addressing the impact of removing Mental Health Act detention and documenting mitigation of escalating risks.
Verbatim wording from the response “Action | Action undertaken by | Target Date | Outcome
Develop a clear protocol based on good practice standards to inform how clinical staff work with older adults with a significant forensic history. | Consultant Psychiatrists for Older Adults | End of September 2022 | Clinical staff consistently assess and plan care that is appropriate for older adults with forensic history.
Ensure that thorough risk assessments will carefully consider the potential impact when removing a service user from detention using the Mental Health Act. | Consultant Psychiatrist for Older Adults / Advanced Clinical Practitioner / Clinical Psychologist | End of September 2022 | Potential risks of removing the restrictions are understood, documented and mitigated and that any escalating risks are recognised and addressed.” Source location Response from NHS Sheffield Health and Social Care
Open published response
Concerns raised 2 Delays in promptly progressing recommendations for section assessment View source Failure to protect people with mental illness while awaiting section assessment 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
Joshua Adey Rennard · 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
Joshua Adey Rennard died by hanging at his parents’ home on 29 September 2021. The principal concern was an eight-day delay in actioning a professional view that he should be assessed for detention under section 2 of the Mental Health Act, with concern that similar delays could place people at risk of harm or 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in promptly progressing recommendations for section assessment
Wider context from the report “5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later . The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future.
5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to protect people with mental illness while awaiting section assessment
Wider context from the report “5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future.
5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays . I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death.
” Open source report
Concerns raised 3 Failure to guarantee funding to properly resource CAMHS View source Lack of urgent mental health service provision for 16- and 17-year-olds View source Lack of available urgent mental health services for 16- and 17-year-olds 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
Aryan Akhgar · 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
Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to guarantee funding to properly resource CAMHS
Wider context from the report “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues, such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and Aryan did not receive any contact from Child and Adolescent Mental Health Services (CAMHS) until 15th January 2018. In evidence I was told that additional resources in the CAMHS service were close to agreement in order to prevent this kind of problem arising in the future. However, this would be subject to a commissioning process from the Clinical Commissioning Group for Sheffield which could not be guaranteed.
5.2 It was accepted in evidence by the Medical Director of the Sheffield Children’s Hospital on behalf of CAMHS that such additional resource was required. The delivery of the necessary funding to properly resource the CAMHS team was not guaranteed .
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of urgent mental health service provision for 16- and 17-year-olds
Wider context from the report “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues , such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and so a referral to Adult Mental Health Services was made in order to obtain this. The adult service refused to take the referral because Aryan was still a child . This gap in the provision between the two services meant that Aryan did not receive the urgent mental health input which he required and there is a risk that other under 18’s in his situation might also suffer the same problem .
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available urgent mental health services for 16- and 17-year-olds
Wider context from the report “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues , such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and Aryan did not receive any contact from Child and Adolescent Mental Health Services (CAMHS) until 15th January 2018. In evidence I was told that additional resources in the CAMHS service were close to agreement in order to prevent this kind of problem arising in the future. However, this would be subject to a commissioning process from the Clinical Commissioning Group for Sheffield which could not be guaranteed.
5.2 It was accepted in evidence by the Medical Director of the Sheffield Children’s Hospital on behalf of CAMHS that such additional resource was required. The delivery of the necessary funding to properly resource the CAMHS team was not guaranteed.
” Open source report
Concerns raised 5 Failure to routinely consult patients' records View source Failure to record the rationale for changes to patient observation regimes View source Lack of clear patient risk assessments View source Inappropriate patient observation regimes View source Lack of appropriate staff training View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith Dransfield · 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
Keith Dransfield died in Northern General Hospital on 30 September 2017 from cerebral hypoxia due to hanging, with psychiatric depression also recorded. The inquest identified concerns about an inappropriate observation regime, inadequate risk assessment, failure to routinely consult patient records, and insufficient staff training.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely consult patients' records
Wider context from the report “During the inquest, evidence showed:-
Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations.
There was not a clear risk assessment of Mr Dransfield.
Staff did not routinely consult patients records.
There was a lack of appropriate training.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale for changes to patient observation regimes
Wider context from the report “During the inquest, evidence showed:-
Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations .
There was not a clear risk assessment of Mr Dransfield.
Staff did not routinely consult patients records.
There was a lack of appropriate training.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear patient risk assessments
Wider context from the report “During the inquest, evidence showed:-
Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations.
There was not a clear risk assessment of Mr Dransfield.
Staff did not routinely consult patients records.
There was a lack of appropriate training.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate patient observation regimes
Wider context from the report “During the inquest, evidence showed:-
Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations.
There was not a clear risk assessment of Mr Dransfield.
Staff did not routinely consult patients records.
There was a lack of appropriate training.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate staff training
Wider context from the report “During the inquest, evidence showed:-
Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations.
There was not a clear risk assessment of Mr Dransfield.
Staff did not routinely consult patients records.
There was a lack of appropriate training.
” 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 refresher training on the policy requirement for a 72-hour post-admission service-user review.
Verbatim wording from the response “The Trust policy requires that a review takes place of each service user on the ward 72 hours after admission. We will ensure that refresher training around the policy and the requirement of the 72 hour review is provided to staff so that an opportunity is not missed for the ward team to consider the needs and presentation of service users in their care to support a clinical assessment around their risks and plan accordingly.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Roll out bespoke suicide-prevention training and continue refining its content using feedback.
Verbatim wording from the response “• The Regulation 28 ruling states that Mr Dransfield was on an inappropriate level of observation at the time of his death. The Trust takes a thorough and proactive approach to the management of risk and, to support our staff in making clinical decisions about levels of risk, the Trust has initiated a programme of bespoke suicide prevention training. This programme of training has commenced, and the Trust has and will continue to review the course content in light of feedback received to improve, refocus and to ensure it is effective and fit for purpose.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Review and revise the inpatient record-keeping procedure to clarify consistent documentation standards.
Verbatim wording from the response “• The Trust’s Standard Operating Procedure for Record Keeping has been reviewed and revised to ensure that expected standards are clear, consistent and all staff are aware & fully understand requirements.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Revise inpatient observation policy, remove ten-minute observations, and inform staff of the resulting safe-practice requirements.
Verbatim wording from the response “• The Trust has reviewed and revised its Policy: Observation of Inpatients – Routine and Enhanced Observations of Patients. In light of national evidence, and in line with accepted best practice, observations at 10 minute intervals have been removed. The Trust has taken steps to ensure that all staff are aware of the new policy and the changes to practice that will be required to implement the policy safely.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Conduct quarterly inpatient-ward audits of care records, risk assessments and care plans for timeliness and quality.
Verbatim wording from the response “Formal audits of care records on all inpatient wards are now conducted on a quarterly basis. These incorporate an audit of care records, risk assessments and care plans for timeliness and quality. The quarterly audits commenced in April 2018.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Check acute-ward care records for timely updating of risk assessments, care plans and significant care changes.
Verbatim wording from the response “• To determine whether the lack of recording of information was a problem in other wards the Nurse Consultant undertook a care records check in each acute ward. These checks included reviewing evidence that risk assessments, care plans and significant changes to care had been regularly updated. These checks identified that records on the acute wards are being updated regularly and key clinical information recorded.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Review and update clinical risk training to strengthen its focus on suicide-risk assessment.
Verbatim wording from the response “The content of our Clinical Risk Training has also been reviewed and updated with an enhanced focus on Suicide Risk Assessment.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Inform staff of named- and associate-nurse responsibilities for knowing service-user care plans and current circumstances.
Verbatim wording from the response “that are in place for them. The Trust found no evidence that notes were looked at nor did the two staff know they were the named nurses for Mr Dransfield on this shift. Staff have been informed of their responsibilities when undertaking the named and associate nurse role and the Ward Manager is responsible for ensuring all Ward staff fulfil their responsibilities effectively.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Deliver the supervision-training programme for staff, including the current two-day course.
Verbatim wording from the response “In addition staff have opportunities for clinical discussion through a range of forums such as ward handovers, incident debriefings, multi-disciplinary team meetings and Care Programme Approach (CPA) Meetings. These enable staff to discuss individual service user risks and their approach to the management of these. In collaboration with Sheffield University the Trust has developed and delivered a programme of supervision training. This year’s programme of 2 day training commenced in September 2018 offering 20 places.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-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 Pilot handheld tablets on Maple Ward to improve timely clinical-record entry and identify observation-level changes and authorisation.
Verbatim wording from the response “• Maple Ward is piloting various clinical improvements, including the use of hand held tablets to improve timeliness and ease of recording clinical information and to move away from paper systems. The system will enable the Trust to extract information about changes to observation levels and more clearly identify who made or authorised the change. ‘Insight’, the Trust’s electronic care record system is not able to provide this information which would have assisted the Coroner’s enquiries had this been available at the inquest.” Source location 2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Open published response
Concerns raised 6 Failure to maintain the flow of clinically relevant risk information View source Failure to take sufficient information into account in risk assessment View source Failure to adequately challenge minimised or concealed suicidal intent and account for parental fears View source Lack of continuity of care caused by excessive involvement of different people View source Failure of the SORT referral process to materialise View source Failure to provide intended treatment View source See 3 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
Alexander Matthew Holt · 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
Alexander Matthew Holt had a history of serious self-harm attempts and died by an impulsive but deliberate act after taking an overdose that was not communicated to staff supervising his accommodation. The concerns included failure to provide intended treatment, failure of a referral process, lack of continuity and information-sharing, and insufficient consideration of risk, including that accommodation staff were unaware of his recent overdose.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the flow of clinically relevant risk information
Wider context from the report “(5) There was a failure to maintain a good flow of information . Most strikingly, the staff at Beaufort Road were not advised of Mr Holt's most recent attempt at self-harm (by overdose of his medication) and were thus unaware of the degree of risk when he returned to that address where support would have been 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take sufficient information into account in risk assessment
Wider context from the report “(6) It was accepted at the inquest that more could have been taken into account in risk assessing Mr Holt .
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately challenge minimised or concealed suicidal intent and account for parental fears
Wider context from the report “(1) The prospect that Mr Holt was minimising or concealing the true extent of his suicidal intent should have been subject to a greater degree of challenge and his parent's fears in this regard should have carried more weight
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care caused by excessive involvement of different people
Wider context from the report “(4) Importantly, Mr Holt's parents described how too many people became involved in his care over a period preventing the necessary degree of continuity .
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the SORT referral process to materialise
Wider context from the report “(3) The referral process for SORT failed to materialise despite repeated concerns expressed .
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide intended treatment
Wider context from the report “(2) It was accepted at the inquest that there was a failure to provide the type of treatment originally intended .
” Open source report
Concerns raised 5 Failure to obtain and retain an accessible patient photograph View source Failure to maintain minimum staffing levels on Hawthorn Ward View source Failure to provide a senior manager solely for management duties View source Failure to escalate unsuccessful staffing replacement efforts to senior management View source Unresolved door security arrangements for secure wards View source See 2 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
Pamela Margaret Bailey · 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
Pamela Margaret Bailey left Hawthorn Ward, Northern General Hospital, on 23 March 2013 and was later found deceased at a secluded location near Ladybower, Derbyshire, on 29 March 2013. The medical cause of death was hypothermia. The substantive concerns included ward door security, staffing levels, and the absence of a photograph available to police when she disappeared.
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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and retain an accessible patient photograph
Wider context from the report “(3) There was no photograph available, of Mrs Bailey, to the Police when she disappeared . This clearly raises a number of difficult issues, as to the obtaining and retaining of a photograph . What decisions have been made in this regard?
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain minimum staffing levels on Hawthorn Ward
Wider context from the report “(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four . Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a senior manager solely for management duties
Wider context from the report “(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties . Please confirm what action is to take place.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate unsuccessful staffing replacement efforts to senior management
Wider context from the report “(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management , having failed to obtain a replacement by contacting either existing staff or flex staff . The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place.
” 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 Sheffield Health Partnership University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unresolved door security arrangements for secure wards
Wider context from the report “(1) Door security – no final decision has been made yet , but my understanding is that it is proposed to introduce a system for all secure wards, whereby there are dual system involving key code and swipe card. Is this the proposed alternative to the current system, and bearing in mind it is now about ten months since this incident , when is it proposed such action should be taken?
” 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