Recipient

Shepherds Bush Medical Centre

First report 4 Nov 2018•Latest report 4 Nov 2018

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Shepherds Bush Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

4 Nov2018
West London
Concerns raised9
1. Failure of the Care Programme Approach to comply with the Code of Practice
2. Inadequate record keeping in the Practice
3. Failure to communicate the Discharge Medication Summary to relevant parties
1. Failure of the Discharge Medication Summary and 7-Day Follow-Up to provide an adequate format
2. Unsatisfactory Practice information collection, recording, saving and dissemination system
3. Failure of the Discharge Medication Summary to be consistent with the Care Programme Approach Policy
4. Inadequate training of Primary Nurses
5. Inadequate supervision of Primary Nurses
6. Inadequate appointment of Primary Nurses
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

PATRICIA PRISCILLA CHAMBERS · 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

Patricia Chambers died by suicide on 11 May 2016 after jumping from the ninth-floor communal walkway of her residence, sustaining non-survivable injuries. The inquest identified deficiencies in her mental-health discharge process, communication and continuity of care, as well as inadequate GP record keeping and document control; the report remained concerned that information could be lost or ignored and pose a risk to future deaths.

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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure of the Care Programme Approach to comply with the Code of Practice
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate record keeping in the Practice
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate the Discharge Medication Summary to relevant parties
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure of the Discharge Medication Summary and 7-Day Follow-Up to provide an adequate format
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Unsatisfactory Practice information collection, recording, saving and dissemination system
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure of the Discharge Medication Summary to be consistent with the Care Programme Approach Policy
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate training of Primary Nurses
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate supervision of Primary Nurses
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
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 Shepherds Bush Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate appointment of Primary Nurses
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised9

Failure of the Care Programme Approach to comply with the Code of Practice

Inadequate record keeping in the Practice

Failure to communicate the Discharge Medication Summary to relevant parties

Failure of the Discharge Medication Summary and 7-Day Follow-Up to provide an adequate format

Unsatisfactory Practice information collection, recording, saving and dissemination system

Failure of the Discharge Medication Summary to be consistent with the Care Programme Approach Policy

Inadequate training of Primary Nurses

Inadequate supervision of Primary Nurses

Inadequate appointment of Primary Nurses