22 May 2026 Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report Somerset
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Concerns raised 3 Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward View source Failure of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia View source Failure to effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward View source
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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.
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AI-generated summary
Jacqueline Marie Antoinette Frehe · 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
Jacqueline Marie Antoinette Frehe, aged 97, was admitted to hospital with swallowing difficulties, vomiting and suspected aspiration pneumonia. Her nil by mouth status was not communicated to ward staff, and she was given food and drink, after which she vomited, deteriorated significantly and died within about two hours. The concerns related to communication and documentation of nil by mouth status and checking this status when patients with dysphagia and suspected aspiration pneumonia arrive on the ward.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward ; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia .
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively communicate patients’ nil by mouth status from the emergency department during transfer to a ward
Wider context from the report “I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that:
1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting ; and
2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward; and
3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia.
” Open source report
28 Aug 2025 Edwin Everett Milne Price · Prevention of Future Deaths report Somerset
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Concerns raised 4 Failure to address gaps in the falls risk assessment and management process for patients admitted from care homes View source Failure to complete falls risk assessments within the first 24 hours of ward admission View source Lack of falls risk mitigation measures View source Failure to obtain nursing home information for falls risk assessments when admitted patients are unable to communicate View source See 1 more concern
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
Edwin Everett Milne Price · 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
Edwin Everett Milne Price, who lived in a nursing home and required hoisting for transfers, was admitted to hospital with diabetic ketoacidosis and fell out of bed the following day. He sustained a fractured humerus and a retroperitoneal bleed, which was recorded as the cause of his death. The principal concerns were that his falls risk assessment was not completed within 24 hours, relevant information was not obtained from the nursing home, and mitigation measures were not put in place.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address gaps in the falls risk assessment and management process for patients admitted from care homes
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments within the first 24 hours of ward admission
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of falls risk mitigation measures
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain nursing home information for falls risk assessments when admitted patients are unable to communicate
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate .
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” 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 Require falls risk assessments within 12 hours of admission, with weekly or condition-triggered reviews, and display patient risk status at the bedside.
Verbatim wording from the response “In April 2023 Somerset NHS Foundation Trust (SFT) and Yeovil District Hospital (YDH) merged organisations to become one Somerset NHS Foundation Trust, and there has been a period, ongoing, where there has been alignment of policies and guidance across the new Somerset NHS FT organisation. At the time of Mr Price’s fall, colleagues in YDH were still working to the legacy policy in place which did not have a time frame in which a Falls Risk assessment was to be completed. The legacy Somerset FT policy and the newly merged one organisational Somerset FT policy both state that an individual must have a Falls Risk Assessment within 12 hours of admission to an inpatient ward, and that this is reviewed if the person moves to another inpatient ward / has a fall / their condition changes.” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.
Verbatim wording from the response “In response to this incident, our acute medical unit (AMU) has introduced a checklist to be completed on admission which involves contacting the patient’s family, care home or community hospital to gather more detailed information about the patient (see appendix 1). The guidance on the patient’s baseline function and the usual mitigations that are in place in their usual residence to reduce the risk of harm” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review reported incidents daily and verify that measures and steps have been taken to mitigate further patient harm.
Verbatim wording from the response “We have launched a test of change with a 5 day a week supernumerary role, titled the Quality and Safety Lead Nurse (2 full time posts) within the medical services group, with clear aims, objectives and job planning, this will follow QI methodology and falls will be part of their patient safety remit. The ADPC and Deputy support a daily review of all incidents reported and the matrons will also review and ensure that all measures and steps have been taken to mitigate any further risk of harm for the patients in our care.” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor falls risk assessment compliance through monthly Core Nursing Metrics audits and additional spot audits.
Verbatim wording from the response “The Deputy Associate Director of Patient Care (ADPC), Matron and Ward Managers are monitoring compliance with the completion of the falls risk assessments and although these are audited monthly through our Core Nursing Metrics, additional spot audits are also being undertaken. These have shown an increase in compliance, however further strengthening in this area is required to ensure an embedded and sustained process of compliance with the expected 12-hour target.” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve Intentional Rounding through role modelling, a patient-centred real-time documentation tool and rollout of the new form across the acute medical unit.
Verbatim wording from the response “We acknowledge also that an appropriate risk assessment on admission would have assisted us to identify Mr Price’s risk more clearly and put sufficient mitigations in place to reduce the risk of harm to him. In addition to the risk assessment, to help us reduce risk to patients, we use an Intentional Rounding tool to assist with care planning and patient involvement. At a minimum a patient is seen two hourly and engaged with, this is in addition to physical observations. From our recent reviews, including learning from Mr Price’s case, it has become clear that there has been a lack of clarity around the purpose and process associated with the meaningful delivery of Intentional Rounding across the Trust.” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate medical matrons 20% of weekly time to clinical ward work supporting training, high-risk patient identification, ward rounds and safety huddles.
Verbatim wording from the response “The medical matrons are now working 20% of their time clinically on our wards each week, supporting with training and education and supporting with the identification of our high-risk patients and are leading ward rounds and safety huddles with the ward senior leadership team.” Source location Response from Somerset NHS Foundation Trust
Open published response
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi View source Failure to provide families with codified risk and safety planning information for first overnight leave View source Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care View source Lack of mandatory menopausal training for relevant clinical practitioners View source Failure to recognise the clinical importance of menopausal symptoms and care View source See 2 more concerns
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
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
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× 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi
Wider context from the report “(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide . It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths .
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with codified risk and safety planning information for first overnight leave
Wider context from the report “(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles.
Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained . This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report “(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations . Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist .
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory menopausal training for relevant clinical practitioners
Wider context from the report “(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism . I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the clinical importance of menopausal symptoms and care
Wider context from the report “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms . If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern . I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing .
” 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 menopause-related education and training for mental health and wider Trust colleagues, including what to identify, consider and where to signpost.
Verbatim wording from the response “There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve clinicians’ assessment of menopause-related mental health presentations through an ongoing task-and-finish group and structured consideration of relevant symptoms and history.
Verbatim wording from the response “There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.” Source location Response from Somerset NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an electronic patient-record prompt in Dialog+ to support consideration of menopause in eligible patients.
Verbatim wording from the response “There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.” Source location Response from Somerset NHS Foundation Trust
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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 Finalize, consult on, approve and produce supportive Section 17 leave guidance for families, carers and people who matter.
Verbatim wording from the response “Following the concerns raised by the family and the coroner in Mrs Potter’s inquest, the Mental Health and Learning Disability Service group have developed supportive guidance for families and people who matter when a patient is on Section 17 Leave from an inpatient unit. This is currently out for feedback from teams and will be shared at the operational meeting next month for approval prior to production via the patient information team. We will also be sharing the draft document with service users and carers to ensure it covers the information that they feel is necessary to support them.” Source location Response from Somerset NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mobile-device filtering cannot currently be added because the available blocking programme is not suitable for mobile devices.
Verbatim wording from the response “Additionally, some desktop devices in some inpatient mental health sites have a browser extension loaded onto the device which can divert users away from certain search terms to a free, 24/7 mental health support site. This can only be used on PCs and is not suitable for mobile devices, but it effectively blocks patients accessing this type of information when they see a search engine on a ward PC e.g. google, safari. Our IT team explained that they could not currently see that this programme is available to download onto mobile devices.” Source location Response from Somerset NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to public NHS Wi-Fi require county-wide implementation and would affect all devices connected to that network.
Verbatim wording from the response “Private devices would not connect to the Trust Network, due to security reasons, and instead would connect to the public ‘NHS Wi-Fi’ which is essentially a connection straight out to the internet. Any changes made to this connection would have to be made county-wide and would affect all devices which connect to it.” Source location Response from Somerset NHS Foundation Trust
Open published response
Concerns raised 4 Delays in outpatient follow-up for ear infections View source Failure to prescribe oral antibiotics at discharge despite microbiology advice View source Failure to establish clear responsibility for patient care View source Failure of separate hospital trusts to provide clinicians with access to each other’s medical records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew James Tizard-Varcoe · 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
Andrew James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in outpatient follow-up for ear infections
Wider context from the report “(2) In addition, the evidence revealed that there were three occasions when Mr Tizard-Varcoe was not followed up as an outpatient in a timely manner (August 2021, November 2021 and February 2022). On one occasion Mr Tizard-Varcoe possibly ran out of antibiotic medication and on another Mr Tizard-Varcoe was discharged without antibiotic medication. The lack of timely follow up appointments resulted in reduced monitoring and assessment and a poor understanding of the effectiveness of treatment and the progression of his ear infection.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe oral antibiotics at discharge despite microbiology advice
Wider context from the report “(3) In addition, on 1 November 2021, Mr Tizard-Varcoe was discharged from the Royal and Devon Hospital without a prescription for oral antibiotics despite advice from microbiologists to do so ; the evidence showed that this was a clinical decision made by a junior ear nose and throat doctor against an improving clinical picture . The discharge was overseen by a consultant from a different specialism due to Mr Tizard-Varcoe’s health needs at the time.
Evidence at the inquest from the responsible ear nose and throat consultant, indicated that he would probably have prescribed antibiotics on advice of microbiologists. Due to the progression of the infection from the ear canal into the bone at the base of the skull there is a real possibility that the clinical presentation did not reflect the true situation and this was a missed opportunity to provide continuity of treatment.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear responsibility for patient care
Wider context from the report “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care . It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of separate hospital trusts to provide clinicians with access to each other’s medical records
Wider context from the report “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records . The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care. It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Somerset Integrated Care Board and the national team to develop an integrated electronic health record across Somerset services.
Verbatim wording from the response “Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.” Source location Response from NHS Somerset
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the ENT waiting list through daily oversight, weekly tracking meetings and fortnightly booking and operational reviews, with activity changes discussed to address demand.
Verbatim wording from the response “Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.” Source location Response from NHS Somerset
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.
Verbatim wording from the response “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.” Source location Response from NHS Somerset
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ENT waiting-list monitoring and patient-service correspondence are considered sufficient for effective outpatient follow-up.
Verbatim wording from the response “Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.” Source location Response from NHS Somerset
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 Funding integrated information technology systems across organisations is beyond the Trust’s control.
Verbatim wording from the response “Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.” Source location Response from NHS Somerset
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 Existing cross-organisational clinical collaboration generally provides sufficient coordination, with shared care used where specifically requested.
Verbatim wording from the response “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.” Source location Response from NHS Somerset
Open published response
24 Jan 2025 Cynthia Mary Gilbert · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 2 Failure to adhere to repositioning care plans for patients at very high risk of pressure ulcer development View source Inadequate quality and efficacy of post-death investigations View source
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. 7
Action
Use education, audits and further ward-based quality-improvement projects to improve pressure-ulcer prevention and management.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025. View source
Action
Review lateral-turning devices, assess available options and risks, and develop a standard operating procedure to support equitable access and safe repositioning.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025. View source
Action
Have matrons work clinically on wards weekly to support training, identify high-risk patients, and lead ward rounds and safety huddles.
Stated completedThe respondent said that this action was complete when they made their response on 4 February 2025. View source
Action
Maintain mandatory pressure-ulcer-prevention eLearning and associated aSSKINg-based education, including Waterlow assessment resources and eAssessment tools.
Stated completedThe respondent said that this action was complete when they made their response on 4 February 2025. View source
Action
Review and align inpatient care-plan templates and documents using the aSSKINg framework.
Stated plannedThe respondent said that this action was planned when they made their response on 4 February 2025. View source
Action
Complete the Intentional Rounding quality-improvement project and roll out the new tool and training package organisation-wide by June 2025.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025. View source
Action
Continue developing robust patient-safety incident learning responses through PSIRF guidance, training and testing, and share review learning through clinical and governance forums.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025. View source See 4 more actions
×
AI-generated summary
Cynthia Mary Gilbert · 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
Cynthia Mary Gilbert, who had cardiac and respiratory illness and reduced mobility, was admitted to hospital after being found unable to stand from the toilet. During her admission, pressure ulcers deteriorated and became infected, and she died from septicaemia on 20 December 2023. Concerns included repeated failures to follow her repositioning care plan despite her very high risk of pressure ulcers, and an unsatisfactory explanation for those failures in the Trust’s post-death investigation.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to repositioning care plans for patients at very high risk of pressure ulcer development
Wider context from the report “a) Mrs Gilbert was noted to have grade 2 tissue damage on admission to hospital. She was assessed as being at very high risk of pressure ulcer development. Her care plan included repositioning every 1 to 2 hours. The Intentional Rounding documents show that, during her time spent on the Old Acute Medical Unit and Coleridge Respiratory Unit (1/9/23 to 20/12/23), Mrs Gilbert remained in the same position in bed for periods of many hours on multiple days.
b) Evidence given by the tissue viability nurse was that the tissue viability team emphasised the importance of repositioning on five separate occasions to the ward staff. The lack of adherence to the repositioning plan continued despite these communications.
c) Mrs Gilbert’s grade 2 tissue damage deteriorated to a grade 4 pressure ulcer during her admission, leading to septicaemia.
d) The lack of adherence to the repositioning care plan for a patient at very high risk of developing pressure ulcers raises a concern for future deaths.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality and efficacy of post-death investigations
Wider context from the report “e) The evidence given by the Trust at the inquest did not provide a satisfactory explanation as to why the repositioning care plan was not adhered to . This raises a concern about the quality and efficacy of the Trusts’ post-death investigation which in turn raises a concern for future deaths.
” 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 Use education, audits and further ward-based quality-improvement projects to improve pressure-ulcer prevention and management.
Verbatim wording from the response “• Education project 2023-24 – which saw 1251 education contacts, pre (1161) and post (481) knowledge questionnaires and audits that saw approximately 500 patient records reviewed within inpatient settings across the project. Further QI projects (with 6 ward areas with higher pressure ulcer rates) were commenced on the back of the results.” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review lateral-turning devices, assess available options and risks, and develop a standard operating procedure to support equitable access and safe repositioning.
Verbatim wording from the response “• There is work, as a national safety alert (cot sides and bed accessories), to review the use of lateral turning devices (integral to mattress or separate support device to aid lateral turning/repositioning). This will include what devices are available to ensure equity of access, risk assessment tools for their use and developing a Standard Operational Procedure (SOP) document.” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have matrons work clinically on wards weekly to support training, identify high-risk patients, and lead ward rounds and safety huddles.
Verbatim wording from the response “The ADPC is carrying out patient and relative engagement walk rounds across all of our wards, during visiting hours, this have been very positive and allows us to hear about areas of notable good practice and areas of concerns that need to be addressed. A plan has been put in place to carry out a 15 steps challenge on several wards across the trust. Night walk rounds are ongoing by the ADPC across both acute sites and have been well received by both staff and the wider MDT. The matrons are now working 20% clinical on our wards weekly supporting with training and education and supporting with the identification of our high-risk patients and are leading on ward rounds and safety huddles with the ward senior leadership team.” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain mandatory pressure-ulcer-prevention eLearning and associated aSSKINg-based education, including Waterlow assessment resources and eAssessment tools.
Verbatim wording from the response “• Introduction of a mandatory eLearning module for Pressure Ulcer Prevention – which notes the importance of repositioning patients and highlights immobility as a key risk factor for developing pressure ulcers. Most recent figures demonstrate 93% compliance with substantive staff mapped to the training.” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and align inpatient care-plan templates and documents using the aSSKINg framework.
Verbatim wording from the response “• Review and alignment of care plan templates/documents across the inpatient settings, which will incorporate the aSSKINg framework as a basis.” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the Intentional Rounding quality-improvement project and roll out the new tool and training package organisation-wide by June 2025.
Verbatim wording from the response “In response to this, a Quality Improvement (QI) project was commenced in September 2024 with an aim to address these variances and improve the overall understanding, application and staff culture, leading to increased patient safety, a reduction in harm and ultimately better outcomes for patients. Since testing the specific role modelling approach for IR across 5 pilot wards, there has been an improved awareness and understanding from colleagues, a reduced number of reported incidences and / or concerns, with fewer patients suffering harm through the adverse effects of pressures leading to pressure damage. A new tool was developed which will capture more accurately the care delivery” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing robust patient-safety incident learning responses through PSIRF guidance, training and testing, and share review learning through clinical and governance forums.
Verbatim wording from the response “Within the Trust there has been a change in learning responses to patient safety incidents, since December 2023 due to the change from the Serious Incident Framework to Patient Safety Incident Response Framework (PSIRF). Previous methodology has” Source location Response from Somerset NHS Foundation Trust
Open published response
26 Jun 2024 Michelle Patricia Moore · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 6 Absence of training and learning on hormone levels, HRT, antidepressants and holistic care View source Lack of understanding and appreciation of the link between menopause and mental health decline View source Lack of continuity and joined-up care between menopause and mental health treatment View source Absence of guidance or published policy on joined-up care for women experiencing menopause View source Lack of understanding and appreciation of the menopause and its effects on women View source Absence of guidance or published policy on the link between menopause and mental health decline View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michelle Patricia Moore · 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
Michelle Patricia Moore, who had a longstanding history of anxiety and an acute deterioration in her mental health, was found deceased at home on 31 October 2023. The inquest concluded with a short-form conclusion of suicide, with the medical cause of death recorded as compression of the neck and suspension by a ligature. The principal concerns were a lack of continuity and joined-up care between treatment for menopausal symptoms and mental health care, and an apparent absence of guidance, training and policy concerning links between menopause and mental health decline.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of training and learning on hormone levels, HRT, antidepressants and holistic care
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and appreciation of the link between menopause and mental health decline
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity and joined-up care between menopause and mental health treatment
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of guidance or published policy on joined-up care for women experiencing menopause
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and appreciation of the menopause and its effects on women
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women ; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of guidance or published policy on the link between menopause and mental health decline
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 menopause training for GPs, mental health clinicians and other relevant colleagues.
Verbatim wording from the response “Somerset NHS Foundation Trust (SFT) is responsible for the provision of care within 16 GP practices across Somerset. Our Director for Primary Care, who is also a GP and menopause specialist, has been leading training on the menopause for both GP’s and clinicians in mental health since the beginning of the year. This has enabled us to deliver bespoke training for colleagues and there is more arranged specifically for the Learning Disability team and Mental Health, as well as physical health colleagues. To support the integration with other GP practices outside of the Trust our Director for Primary Care works closely with our Medical Director of Integrated and Primary Care to determine if we can offer training/sharing of information more” Source location Response from Somerset NHS
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 Explore national menopause resources to support development of understanding and training.
Verbatim wording from the response “In addition, our Director of Primary Care is involved in the Newson Health Menopause Clinic and is exploring more widely through that resource any other national resources how we can use it to support the development of understanding and training.” Source location Response from Somerset NHS
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 Prepare guidance for colleagues on considering menopause and perimenopause during assessment of relevant patients.
Verbatim wording from the response “Within the Mental Health and Learning Disability Service Group a Task and Finish group has been established to look further at this concern. It is a multi-disciplinary group and has been meeting for the last few months to determine how best we can share information with colleagues. The initial plan is to share with colleagues’ guidance on considering menopause/perimenopause when assessing this patient group. Key themes to consider will be:” Source location Response from Somerset NHS
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 whether a menopause assessment prompt can be added to Dialog+.
Verbatim wording from the response “1. Considering perimenopause and menopause as part of assessment – remember to ask the question, and we are establishing if there is potential to put a prompt in Dialog+” Source location Response from Somerset NHS
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 Share menopause and mental-health assessment guidance across inpatient and community services.
Verbatim wording from the response “These points are relevant to both inpatient and community services, and the guidance will be shared within the coming weeks.” Source location Response from Somerset NHS
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 Operate a multidisciplinary task and finish group to develop information-sharing arrangements on menopause and mental health.
Verbatim wording from the response “Within the Mental Health and Learning Disability Service Group a Task and Finish group has been established to look further at this concern. It is a multi-disciplinary group and has been meeting for the last few months to determine how best we can share information with colleagues. The initial plan is to share with colleagues’ guidance on considering menopause/perimenopause when assessing this patient group. Key themes to consider will be:” Source location Response from Somerset NHS
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 Make Royal College of Psychiatrists menopause training available to psychiatry colleagues.
Verbatim wording from the response “Clinicians in psychiatric services can access the online training offered by the Royal College of Psychiatrists and this was referred to at the inquest by our consultant witness who has undertaken the training. This resource is available to all our psychiatry colleagues and will be included in the guide that is being prepared, please see below.” Source location Response from Somerset NHS
Open published response
10 Apr 2024 Cariss Lucy Stone · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 2 Failure to routinely supply staff conducting patient observations with ligature cutters View source Lack of adequate staff training and understanding of the level two observations policy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Cariss Lucy Stone · 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
Cariss Lucy Stone was detained in a Psychiatric Intensive Care Unit and self-harmed on multiple occasions, including by attaching a ligature around her neck. During an interval in observations, she applied a ligature with fatal effect, and the healthcare assistant who found her did not have a ligature cutter. The concerns identified were possible inadequate understanding and training regarding observation requirements, including for agency staff, and the lack of routine access to ligature cutters for staff conducting observations.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely supply staff conducting patient observations with ligature cutters
Wider context from the report “(2) In a ward where self-harm including use of a ligature was not uncommon there was concern that members of staff and in particular those involved in carrying out observations on patients were not routinely supplied with ligature cutters .
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate staff training and understanding of the level two observations policy
Wider context from the report “(1) The Trust’s current policy for level two observations requires staff to observe a patient not less than five times an hour at random intervals which shall not be more than 15 minutes apart. A possible training issue was revealed during the inquest. Some members of staff who gave evidence at the hearing and in particular one senior member of staff did not appear to have a clear understanding of the policy and there was concern that agency staff might not receive adequate 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 Implement revised observation policy with clearer level 2 guidance, irregular intervals, multidisciplinary decisions and dedicated staffing for high-frequency observations.
Verbatim wording from the response “Since this reported incident involving Miss Stone in 2019, Somerset NHS Foundation Trust Policy on Observation while maintaining Safety and Engagement has undergone a number of revisions to reflect changes in practice and to incorporate learning from patient safety incidents. The most recent version was published in May 2024 and builds upon existing policy and practice with the aim of providing greater clarity and improved clinical governance around practice of observation.” Source location Response from Somerset NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether staff should carry ligature cutters during level 2 and 3 observations and assess available cutters for the safest option.
Verbatim wording from the response “Consideration and discussion is underway to consider staff holding a ligature cutter whilst carrying out level 2 and 3 observations for patients who present with a risk of self-harm/suicide. This would be alongside a further review of the types of ligature cutters that are available on the market, to ensure they have the safest option. Once agreed we will seek to roll this out across all the MH wards and update our Observation policy to provide greater detail on the process.” Source location Response from Somerset NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require and monitor competence assessment, supervised observation rounds and suicide-prevention training for all staff undertaking observations, including bank and agency staff.
Verbatim wording from the response “All staff, who undertake observations, are required to complete an assessment of competence, which will be assessed by a competent Registered Mental Health nurse and who has a minimum of 1 year post registration experience. This is the sole requirement for staff who are employed on the Trust’s bank or via a nursing agency.” Source location Response from Somerset NHS Foundation Trust
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 The balance of patient and staff safety risks does not support staff routinely carrying ligature cutters on wards with increased violence and aggression risks.
Verbatim wording from the response “We considered the potential risks of supplying staff on wards like Holford (PICU) and Ash ward (low secure inpatient rehabilitation and recovery unit for male adults with mental health difficulties) where there is an increased risk of violence and aggression with ligature cutters. This required careful consideration of both the risks to patients, who present with self-harm and suicide versus the risk of patients who present with high levels of violence and aggression or with a documented forensic history. Our conclusion from this review with the ward teams and senior leaders is that the balance of risk would not support staff routinely carrying ligature cutters.” Source location Response from Somerset NHS Foundation Trust
Open published response
6 Jun 2022 Andrew Arden Nixon · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Failure to involve family members and carers fully in risk assessment and decisions View source Lack of an early process for engaging carers View source Lack of criteria for identifying carers for early carer assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Arden Nixon · 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
Andrew Arden Nixon’s mental health deteriorated from around October 2020, and after referral and assessment by mental health services he was found suspended by a ligature in wooded grounds in North Dorset on 3 March 2021. The principal concerns were that family members or carers were not fully involved in risk assessment and care planning, and that criteria for considering a Carer’s Assessment were not applied at the earliest appointment.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family members and carers fully in risk assessment and decisions
Wider context from the report “2. I have concerns with regard to the following:
i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach.
ii. There should be criteria to be applied as to who should be considered for a Carer’s Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help.
iii. Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an early process for engaging carers
Wider context from the report “2. I have concerns with regard to the following:
i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach.
ii. There should be criteria to be applied as to who should be considered for a Carer’s Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help.
iii. Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of criteria for identifying carers for early carer assessment
Wider context from the report “2. I have concerns with regard to the following:
i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach.
ii. There should be criteria to be applied as to who should be considered for a Carer’s Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help.
iii. Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.
” 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 Maintain Triangle of Care accreditation and deploy 42 leads across mental health and learning-disability services.
Verbatim wording from the response “Somerset NHS Foundation Trust (SFT) Mental Health and Learning Disabilities Directorate has been part of the Triangle of Care accreditation scheme since it began. On 12 May 2016, the Trust was awarded a second quality star by ████████ of the Carers’ Trust.” Source location Response from NHS Somerset
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 Add carer-assessment review and family-liaison checks to Home Treatment Team review checklists and caseload boards.
Verbatim wording from the response “• The Home Treatment Team plan to include carers assessment in their checklist for clinical review meetings so that carers assessment is reviewed on a weekly basis, as well as to their caseload boards where carers assessment will be marked as complete once families and carers have been asked about their carer needs and been signposted to relevant information. The team currently review” Source location Response from NHS Somerset
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 family and carer involvement in care planning, safety planning, contact details and confidentiality monitoring through routine caseload management.
Verbatim wording from the response “• As part of our Directorate governance processes, The Mental Health Directorate expects all staff to complete a routine caseload management tool. This includes monitoring of family and carer involvement in care planning (in Dialog+), family and carers involvement in safety/escalation planning, collecting Next of Kin and carer contact details, and to check that confidentiality is discussed and reviewed regularly with the patient.” Source location Response from NHS Somerset
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 Launch a co-produced quality-improvement project to strengthen earlier family and carer involvement in care planning, decision-making and risk-information sharing.
Verbatim wording from the response “• We will design a Quality Improvement project which is co-produced with experts by caring, experts by experience and experts by training to explore further mechanisms by which we can ensure greater and earlier family and carer involvement in care planning, and decision making, and sharing risk information.” Source location Response from NHS Somerset
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 Add reminders about exploring carers assessments to clinical risk training.
Verbatim wording from the response “• We will add more specific reminders to explore carers assessments with patients and their families/carers in our clinical risk training.” Source location Response from NHS Somerset
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 Recommend that frontline assessors record previous carer involvement with mental health services.
Verbatim wording from the response “We will be able to gather information about previous patient involvement from our electronic records and we will add carer involvement as a recommendation to frontline staff undertaking assessments.” Source location Response from NHS Somerset
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 Remind staff to record consultation attendees and patients’ preferred people for involvement in care.
Verbatim wording from the response “Recording who is present during a consultation should be a routine part of record keeping and we will ensure that staff are reminded of this. Dialog+ also includes a tick box and free text box with the prompt to establish at an early stage who the patient would wish to involve in their care.” Source location Response from NHS Somerset
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 Recruit Community Mental Health Engagement workers to provide outreach and encourage family and carer attendance at assessment meetings.
Verbatim wording from the response “• As well as peer workers in home treatment teams, we are currently recruiting Engagement workers to Community Mental Health Services who will also provide an outreach function to families and carers to encourage attendance at assessment meetings.” Source location Response from NHS Somerset
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 simplifying electronic carer registration and referral processes in RiO.
Verbatim wording from the response “• The above project also identified via staff focus groups that there are difficulties with the processes required in our electronic record system for carer registration and referral.” Source location Response from NHS Somerset
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 Update clinical staff on carer-support resources and when to explore carers assessments.
Verbatim wording from the response “• We will provide an update to all clinical staff about ensuring patients and their carers are aware of carers support resources and to explore with patients and their carers whether assessment is indicated, for example where a carer is expressing difficulty and stress because of their caring role.” Source location Response from NHS Somerset
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 sharing of care plans with families at hospital discharge and checking understanding of care and safety plans.
Verbatim wording from the response “• A recent quality improvement project (2020-21) focused on initiatives to increase family and carer involvement and has led to the roll out of a plan to share care plans with families at discharge from hospital, and check understanding of care/safety plans, and a shared safety planning initiative in Children’s services.” Source location Response from NHS Somerset
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 Require discharged patients to have a consented, co-produced safety plan shared with identified family, friends or carers where possible.
Verbatim wording from the response “• All patients discharged from the service should have a co-produced safety plan which is shared with consent wherever possible with identified family/friend of carer. Our routine record keeping audit includes this as part of its assurance.” Source location Response from NHS Somerset
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 Recruit Home Treatment Team peer-support workers to provide outreach and check carers’ understanding of care plans.
Verbatim wording from the response “• Home Treatment Teams are in the process of recruiting peer support workers who will undertake to perform an outreach function to families and carers on the caseload, checking attendance and understanding of the plan of care.” Source location Response from NHS Somerset
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 Launch a quality-improvement project to refresh the Triangle of Care strategy, beginning in Community Mental Health Services.
Verbatim wording from the response “A Quality Improvement Project is currently being launched to refresh the Triangle of Care strategy beginning in Community Mental Health Services. This project has support from corporate and directorate colleagues who attend the mental health Serious Incident Review Group and includes the Trust’s Medical Director for Mental Health and Community Services as well as the Trust’s Associate Medical Director for Mental Health and Learning Disability Care. Preliminary meetings are scheduled during August to support the QI project and the Triangle of Care Steering Group.” Source location Response from NHS Somerset
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 refresh Triangle of Care eLearning using feedback and incident learning.
Verbatim wording from the response “The Triangle of Care eLearning remains available to all staff but is due a review and refresh to take account of learning from feedback and incidents.” Source location Response from NHS Somerset
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 consideration and discussion of carers assessments in the caseload management tool.
Verbatim wording from the response “• We will include the standard that carers assessment has been considered and discussed with family and carers in the caseload management tool.” Source location Response from NHS Somerset
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 family and carer invitations in in-person and online appointment letters.
Verbatim wording from the response “• All appointment letters currently include a standard invitation to bring family members/friends or carers and we have ensured that this is also included in invitations for online appointments using ‘Attend anywhere’, our online platform.” Source location Response from NHS Somerset
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 Service capacity limits carers assessments to main carers, preventing assessments being offered to all carers.
Verbatim wording from the response “It is important that staff make available to all carers the opportunity to have a carer’s assessment or signpost to other stakeholders for support. Whilst carers assessment may not be indicated in all cases, and our service capacity means we would only be able to include providing carers assessments to main carers only, it is possible that staff may not be fully aware of the availability of the resource or of who might benefit from it.” Source location Response from NHS Somerset
Open published response
Concerns raised 3 Lack of accessibility to records held by different healthcare trusts View source Failure of Emergency Department staff to access vital pre-admission and paramedic records View source Lack of access by other police forces to information held on individual police force systems 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
Felicity Jane Clough · 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
Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accessibility to records held by different healthcare trusts
Wider context from the report “i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts . I would request consideration is given to the sharing of records between healthcare trusts.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department staff to access vital pre-admission and paramedic records
Wider context from the report “iii. I have concerns that future deaths could occur at Yeovil District hospital due to the missing of vital information within the pre admission documentation due to the fact that the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident and Emergency department. I request that consideration is given to issuing further guidance to remind staff of the need to review this documentation or amending the current policy in 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access by other police forces to information held on individual police force systems
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces , especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others.
” Open source report
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment 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
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
25 May 2018 Robin Damien Richards · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 8 Failure to inspect CQC-registered placement suitability View source Failure of communication with family and between Trust staff View source Shortage of suitable supported accommodation for people diagnosed with Asperger's Syndrome View source Failure to communicate directly with the person in crisis View source Inadequate risk assessment and subsequent risk management View source Failure of communication between Trust staff and placement staff View source Lack of clarity in discharge plans and placement expectations View source Inadequate handover of mental health care information View source See 5 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
Robin Damien Richards · 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
Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inspect CQC-registered placement suitability
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication with family and between Trust staff
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitable supported accommodation for people diagnosed with Asperger's Syndrome
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate directly with the person in crisis
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate risk assessment and subsequent risk management
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between Trust staff and placement staff
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in discharge plans and placement expectations
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate handover of mental health care information
Wider context from the report “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests.
(2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected.
(3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified;
a) Poor communication with family and between Trust staff.
b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement.
c) An inadequate handover.
d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him.
e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards
” Open source report
4 Oct 2017 Sofia Ann Legg · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 6 Delays in access to CBT View source Failure to urgently contact the school about the need for psychiatric input View source Insufficient detail in care plans to record safeguarding requirements View source Failure to obtain urgent psychiatric input View source Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change View source High threshold for CAMHS referral View source See 3 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. 12
Action
Hold weekly multidisciplinary meetings with psychiatrists to guide complex case discussions and identify cases requiring psychiatric input.
Stated completedThe respondent said that this action was complete when they made their response on 27 November 2017. View source
Action
Implement investigation terms and oversight processes that define family needs and ensure key questions are addressed.
Stated completedThe respondent said that this action was complete when they made their response on 27 November 2017. View source
Action
Provide psychiatric liaison nurses at Somerset acute hospitals to assess self-harm and suicidal presentations and coordinate follow-up or paediatric admission.
Stated completedThe respondent said that this action was complete when they made their response on 27 November 2017. View source
Action
Reduce waiting times for specialist therapies, including CBT, to weeks rather than months.
Stated completedThe respondent said that this action was complete when they made their response on 27 November 2017. View source
Action
Restructure initial-assessment clinics to support staff decision-making and involve psychiatrists and senior clinicians earlier.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017. View source
Action
Operate a CAMHS Single Point of Access to screen referrals consistently, provide referrer advice, and monitor thresholds.
Stated completedThe respondent said that this action was complete when they made their response on 27 November 2017. View source
Action
Continue staff risk training and team meetings to reinforce clear crisis plans explaining supervision requirements to young people and parents.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017. View source
Action
Ensure CAMHS care plans are explicit and communicate information clearly, with implementation monitored through clinical supervision.
Stated completedThe respondent said that this action was complete when they made their response on 27 November 2017. View source
Action
Train key investigators in national investigation tools and techniques and establish a trained investigator cohort.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017. View source
Action
Work with commissioners, schools, and staff toward routinely sharing suicide-risk assessments and crisis plans with schools.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017. View source
Action
Further review the investigation into Sofia’s death to challenge disputed statements and produce a balanced, sensitive report.
Stated plannedThe respondent said that this action was planned when they made their response on 27 November 2017. View source
Action
Benchmark CAMHS Tier 3 thresholds against national definitions and commissioned provision to identify whether thresholds require adjustment.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017. View source See 9 more actions
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AI-generated summary
Sofia Ann Legg · 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
Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI Report.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to CBT
Wider context from the report “2. Availability of CBT. Sofia was placed on a 6 month waiting list for CBT . This delay appears considerable .
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to urgently contact the school about the need for psychiatric input
Wider context from the report “4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school , where she would be during the following days to a psychiatrist . Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in care plans to record safeguarding requirements
Wider context from the report “4. The recollections of Sofia’s care co-ordinator and Sofia’s mother as to the meeting of the 19th September were at odds with each other. Sofia’s care co-ordinator recollected in her evidence telling Sofia’s mother that Sofia was not to be left alone. Sofia’s mother deemed the impression from Sofia’s care co-ordinator's evidence as of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia’s care plan which made no mention of her not being left alone and it was not reflected in the care co-ordinator’s actions in not urgently contacting Sofia’s school, where she would be during the following days to a psychiatrist. Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain urgent psychiatric input
Wider context from the report “3. Sofia’s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance .
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change
Wider context from the report “5. Language used in the SIRI Report was felt to be inappropriate . The SIRI Report effectively said if the care plan had been followed the outcome might have been different and that no change in clinical practice would have resulted in any different outcome. I do not believe either of these statements were true.
” 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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation High threshold for CAMHS referral
Wider context from the report “1. Access to CAMHS. Sofia was rejected for referral in April 2015 . Might a lower threshold and earlier proactive interventionist policy has been of positive benefits to Sofia.
” 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 Hold weekly multidisciplinary meetings with psychiatrists to guide complex case discussions and identify cases requiring psychiatric input.
Verbatim wording from the response “2.3 During 2017 the way initial assessments are performed has also changed. This includes the re-structuring of clinics to better support all staff in their decision making and to include psychiatrists and senior clinicians at an earlier stage. Weekly multi-disciplinary meetings with psychiatrists in attendance have been implemented to guide staff through complex case discussions and identify those cases which may need their input.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement investigation terms and oversight processes that define family needs and ensure key questions are addressed.
Verbatim wording from the response “5.3 The scope and terms of reference for the investigation will be clearly defined to include the needs of families and there will be oversight throughout the process to ensure key questions are asked and answered, this will ensure that the Trust achieves credible investigations. This new process has already been implemented.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide psychiatric liaison nurses at Somerset acute hospitals to assess self-harm and suicidal presentations and coordinate follow-up or paediatric admission.
Verbatim wording from the response “3.4 In addition the Trust now has a team of highly experienced psychiatric liaison nurses based at both acute hospitals in Somerset, these nurses assess young people who self-harm or experience suicidal thoughts on presentation to an emergency department. If the child/young person is discharged and they require further CAMHS input this information is communicated to the relevant local team for follow up. This team can also admit to the paediatric ward if they need to keep a young person safe and this would prevent a delay in care if the young person could only be seen by a psychiatrist to undertake these assessments.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce waiting times for specialist therapies, including CBT, to weeks rather than months.
Verbatim wording from the response “2.1 The Trust agrees that a six month waiting time for CBT is unacceptable and has been working hard to reduce this. Waiting times for all specialist therapies have been successfully reduced and CBT waiting times in the Trust are now measured in weeks, rather than months. However, CBT is not an emergency intervention and a review of Sofia’s care has led us to conclude that she should have been offered a more generic, therapeutic intervention with more frequent appointments at an earlier stage. This would involve using psychoeducation and a range of therapeutic techniques to engage and build a trusting relationship with a focus on understanding and managing risk.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restructure initial-assessment clinics to support staff decision-making and involve psychiatrists and senior clinicians earlier.
Verbatim wording from the response “2.3 During 2017 the way initial assessments are performed has also changed. This includes the re-structuring of clinics to better support all staff in their decision making and to include psychiatrists and senior clinicians at an earlier stage. Weekly multi-disciplinary meetings with psychiatrists in attendance have been implemented to guide staff through complex case discussions and identify those cases which may need their input.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a CAMHS Single Point of Access to screen referrals consistently, provide referrer advice, and monitor thresholds.
Verbatim wording from the response “1.2 Over the past year the Trust has introduced a Single Point of Access (SPA) for CAMHS and the remit has been to more consistently screen referrals, allow more time for advice and discussion with referrers and to maintain and monitor service thresholds. We believe this is making a difference by improving access as well as improving the quality of the advice and guidance that is given.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue staff risk training and team meetings to reinforce clear crisis plans explaining supervision requirements to young people and parents.
Verbatim wording from the response “4.3 It has been fully recognised that family members need to be involved at the earliest stage when young people are expressing suicidal ideation and given time to absorb information and to process advice. The CAMH service is continuing to work with staff through risk training and via local team business meetings to emphasise the importance of crisis plans which give advice to both the young” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure CAMHS care plans are explicit and communicate information clearly, with implementation monitored through clinical supervision.
Verbatim wording from the response “4.1 It has been recognised that the recollections of Mrs Legg and Sofia’s care co-ordinator are not in agreement with regards to the level of detailed safety advice given. Mrs Legg herself has told us that we, as a service, may not fully understand how challenging this situation was for her as a parent. She was being asked to absorb new information about her daughter’s mental state and her risk of ending her life, which was new and shocking for her. I extend again my own and the Trust’s sincere apologies to Mrs Legg for this. The Trust appreciates and fully understands this feedback given by Sofia’s mother and realises that services need to work much harder to help families understand the impulsive and fluctuating nature of suicide risk in young people. CAMHS practitioners have been made aware of the importance of ensuring care plans are explicit and information is written clearly.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train key investigators in national investigation tools and techniques and establish a trained investigator cohort.
Verbatim wording from the response “5.2 The Trust has prioritised the need for all investigators to have the knowledge and ability to conduct a thorough, accurate and reliable investigation using national tools and techniques. Training of key staff in the use of these national tools and techniques has already commenced and by the end of 2017 a cohort of trained investigators will be in place.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with commissioners, schools, and staff toward routinely sharing suicide-risk assessments and crisis plans with schools.
Verbatim wording from the response “4.4 A recently conducted review of Sofia’s care has highlighted the issue of communication with the school as one of the most significant areas of learning for the service. It has been concluded that the school might have been able to take different actions in their care of Sofia had they been aware of the increased risk. It has not been standard for CAMHS staff to share risk assessments and crisis plans with schools and has been a matter for individual clinical judgement. We believe that in cases where young people are expressing suicidal ideation then this information should be shared with schools as standard practice. This will involve cultural and practical changes and will have implications for our education colleagues. We are starting a process of talking with the CCG, schools and our staff to work towards implementing this approach as standard.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further review the investigation into Sofia’s death to challenge disputed statements and produce a balanced, sensitive report.
Verbatim wording from the response “5.6 In addition the Trust will further review the investigation into the death of Sofia. This review will seek to challenge the statements made and provide a balanced and sensitive report. This is due to complete by the end of January 2018.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Benchmark CAMHS Tier 3 thresholds against national definitions and commissioned provision to identify whether thresholds require adjustment.
Verbatim wording from the response “1.6 As part of this review we are also currently undertaking work to benchmark our own internal threshold processes for CAMHS Tier 3, with the national definition of what a Tier 3 service is expected to provide, and with what is commissioned: to ensure that we have our threshold in the right place, and that if it is set too high that we can identify that, to ensure that we look to get the right level commissioned.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited psychiatrist numbers mean psychiatrists cannot see every case involving suicidal ideation; experienced senior clinicians therefore assess and manage many cases.
Verbatim wording from the response “3. Sofia’s care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance.” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited Tier 3 CAMHS capacity constrains adopting a lower referral threshold and providing earlier proactive intervention.
Verbatim wording from the response “1. Access to CAMHS. Sofia was rejected for referral in April 2015. Might a lower threshold and earlier proactive interventionist policy have been of positive benefits to Sofia?” Source location 2017-0293-Response-by-Somerset-NHS-Trust
Open published response
14 Nov 2013 Kevin Paul SUTTON · Prevention of Future Deaths report West Somerset
View report summary
Concerns raised 1 Failure to provide care plans 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.
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AI-generated summary
Kevin Paul SUTTON · 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
Kevin Paul SUTTON, who had Huntington’s disease and continuing depression, was discharged to Halcon House and took his own life on 3 September 2012. During the inquest, evidence indicated that no care plan had been prepared, so Halcon House staff were not made aware of the suicidal risk; the stated concern was the Trust’s failure to provide care plans.
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 Somerset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide care plans
Wider context from the report “Failure by the Trust to provide care plans.
” Open source report
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Request correction
Addressed to Yeovil District Hospital NHS Foundation Trust, now represented here by Somerset NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations