1 Apr 2026 Lajos MANDRIK · Prevention of Future Deaths report West London
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Concerns raised 2 Failure to attempt engagement during patient observations View source Failure to conduct general hourly observations beyond a headcount View source
Responses linked to these concerns
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AI-generated summary
Lajos MANDRIK · 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
Lajos MANDRIK died on 13 September 2023 after hanging himself during a period when no staff member was allocated to carry out intermittent observations on Ellis Ward at Tolworth Hospital. The report’s principal concern is that general and intermittent observations appeared not to be carried out in accordance with the Trust’s policy, including the required attempt at engagement.
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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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt engagement during patient observations
Wider context from the report “The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement . The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations , in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient . General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now).
This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest.
It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy . If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct general hourly observations beyond a headcount
Wider context from the report “The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now).
This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest.
It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy . If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward).
” 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 Implement the revised Observation and Engagement Policy, including clarified expectations for general and intermittent observations and an agreed staff code of conduct.
Verbatim wording from the response “the Nurse in Charge as well as weekly assurance Audits. There was continuous work done on revising the policy and adjustments made in line with the existing training package to include an agreed code of conduct that clearly lays out expectation on roles and responsibility by staff who undertake observation.” Source location Response from South West London and St George's Mental Health NHS 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 Pilot digital recording of general and intermittent observations across six inpatient wards, supported by PDSA cycles and evaluation.
Verbatim wording from the response “The Trust has an existing digital system that supports recording Constant and Enhanced Observation. To improve consistency, transparency and auditability of observations, the Trust will move general and intermittent observations to the same digital format. To enable this process, there is a plan to pilot the use of digital technology, ‘e-obs’ in 6 inpatient wards across the organisation, to ensure a collaborative approach to change in practice. This digital system will support a more detailed documentation which will include a safety and wellbeing check on patients during both general and intermittent observation. A set of PDSA cycles will be undertaken to ensure the change is supported and understood by staff. With a final evaluation of the pilot completed by 31 July 2026, with a planned phased roll-out across all inpatient wards by 31 October 2026, subject to evaluation findings.” Source location Response from South West London and St George's Mental Health NHS 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 Deliver organisation-wide webinars launching the revised observation policy for substantive, bank and agency staff.
Verbatim wording from the response “The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows:
- The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting.
- Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff.
- The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant” Source location Response from South West London and St George's Mental Health NHS 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 Increase leadership oversight through regular ward visits to support safe observation practice and policy compliance.
Verbatim wording from the response “We will also increase visibility of leadership by regular ward visits to support staff in safe management of patients on observation and better oversight on whether the Observation Policy is being followed by staff. This oversight will:” Source location Response from South West London and St George's Mental Health NHS 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 Provide staff with credit-card-sized observation memory cards distinguishing observation levels and minimum engagement expectations.
Verbatim wording from the response “In addition, a new credit card sized memory Card has been created as an aid-memoir that can be kept on staff’s lanyard that will support staff at a glance to” Source location Response from South West London and St George's Mental Health NHS 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 Create and deploy a dashboard showing the quality of observations to clinical staff.
Verbatim wording from the response “The Trust also has a Nursing Optimisation & Workforce Programme that is focusing on compliance with observation and the quality of these. Having learned from the death of Mr Mandrik, the programme has reviewed the quality of observations and aims to ensure that all observations are supportive of the patient and are a therapeutic intervention. A dashboard to understand the quality of observation is being created and aim to be in use and visible to clinical staff in June 2026.” Source location Response from South West London and St George's Mental Health NHS 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 Update observation e-learning and require staff to complete it alongside a new competency framework demonstrating understanding and compliance.
Verbatim wording from the response “The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows:
- The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting.
- Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff.
- The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant” Source location Response from South West London and St George's Mental Health NHS 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 Implement mandatory competency-based observation assessments and reinforce staff roles, responsibilities and expectations through training and regular supervision.
Verbatim wording from the response “We acknowledge that HCAs were specifically referenced in HM Coroner’s concerns and recognising that sustainable improvement requires cultural as well as procedural change, the Trust is implementing a programme of workforce development for all disciplines across all inpatient wards including:” Source location Response from South West London and St George's Mental Health NHS 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 Continue monitoring the effectiveness of observation improvements and embedding them into routine practice.
Verbatim wording from the response “We will continue to monitor the effectiveness of these actions and ensure that they are embedded into routine practice.” Source location Response from South West London and St George's Mental Health NHS 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 General observations are intended to locate patients and visually check wellbeing, while meaningful engagement applies to intermittent observations.
Verbatim wording from the response “1. Trust Policy – Clarification of the observation model
The Trust has undertaken a comprehensive review of the Observation and Engagement Policy in line with NICE guidelines with an increased focus on quality observations to improve patient’s experience as well as to provide greater clarity regarding expectations for all levels of observation. Specifically, the revised policy outlines the expectation for staff carrying out General and Intermittent Observation stating: General observations are the baseline observation applied within the trust, these low-level observations are performed hourly with the intention of locating a patient and visually checking their wellbeing.” Source location Response from South West London and St George's Mental Health NHS Trust
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8 Aug 2025 Gareth Ian JACKSON · Prevention of Future Deaths report Inner West London
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Concerns raised 2 Failure to align acute ward operational, leave and risk management policies View source Failure to give leave and off-ward safety planning sufficient prominence in review, handover and planning templates View source
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AI-generated summary
Gareth Ian JACKSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gareth Ian JACKSON, who was at high risk of suicide and a voluntary patient in an acute psychiatric ward, was permitted unescorted leave despite a plan requiring escorted leave. He left the hospital and was struck by a train, dying from multiple traumatic injuries on 22 June 2022. The principal concerns were failures to communicate, document and follow his leave-safety plan, inadequate risk assessment, unaligned policies, and insufficient controls over access to the route out of the hospital.
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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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to align acute ward operational, leave and risk management policies
Wider context from the report “I heard evidence that there had been changes to the policies and templates aimed at addressing risk around leave and safety off ward. This was still ongoing. It was accepted in evidence that the acute ward operational policy and leave policy needed to be reviewed again to make sure the various policies including risk management policies were aligned . For example on the Day 2 checklist for review there was no placeholder for leave/off ward safety management. I was told that there was a positive move to review thinking around risk more as safety rather than simply as risk management, but this was a new concept. I noted that in the templates now used to consider nursing reviews and handovers, there was no specific place to consider leave management and safety around this, expecting it instead to be addressed in the plan – albeit there was a reminder to consider this on the template. To that extent it appeared little substantial had changed from the process before, and the policies remained unaligned . I am concerned that safety planning around leave/going off ward/unit as a voluntary patient has not been given the prominence it requires, as was required in the case of Gareth where the plan for his safety off ward had not been identified by staff on Ward 2 effectively. As such my concern as to future death if this were not to be unaddressed comprehensively, continues.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give leave and off-ward safety planning sufficient prominence in review, handover and planning templates
Wider context from the report “I heard evidence that there had been changes to the policies and templates aimed at addressing risk around leave and safety off ward. This was still ongoing. It was accepted in evidence that the acute ward operational policy and leave policy needed to be reviewed again to make sure the various policies including risk management policies were aligned. For example on the Day 2 checklist for review there was no placeholder for leave/off ward safety management . I was told that there was a positive move to review thinking around risk more as safety rather than simply as risk management, but this was a new concept. I noted that in the templates now used to consider nursing reviews and handovers, there was no specific place to consider leave management and safety around this , expecting it instead to be addressed in the plan – albeit there was a reminder to consider this on the template. To that extent it appeared little substantial had changed from the process before, and the policies remained unaligned. I am concerned that safety planning around leave/going off ward/unit as a voluntary patient has not been given the prominence it requires , as was required in the case of Gareth where the plan for his safety off ward had not been identified by staff on Ward 2 effectively. As such my concern as to future death if this were not to be unaddressed comprehensively, continues.
” 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 Establish an inpatient-rotation induction programme covering risk assessment and documentation for junior doctors.
Verbatim wording from the response “▪ Established a new inpatient-rotation induction programme for junior doctors covering requirements for risk assessment and documentation, especially for informal patients granted leave.” Source location Response from South West London and St Georges Mental Health NHS 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 Update Collaborative Clinical Safety Training to cover leave safety planning, risk assessment and the legal framework for informal patients.
Verbatim wording from the response “Training – The Collaborative Clinical Safety Training (CCST) has been updated to incorporate learning and reflections from this case, with emphasis on leave safety planning, risk assessment and the legal framework around informal patients.” Source location Response from South West London and St Georges Mental Health NHS 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 leave procedures, safety-planning, escalation and documentation requirements to the Adult Inpatient Operational Policy and admission checklist, aligned with related policies.
Verbatim wording from the response “Enhanced Adult Inpatient Operational Policy – A new dedicated section on Leave has been added to provide clarity for our staff, covering:” Source location Response from South West London and St Georges Mental Health NHS 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 Update multidisciplinary, nursing handover and care-plan review templates with dedicated leave safety-plan sections.
Verbatim wording from the response “Updated Handover and Review Templates – The MDT and Nursing Handover templates, as well as the Care Plan Review Meeting (CPRM) template, have been updated to include a dedicated section for reviewing safety plans linked to leave. A new heading, “Safety Plan for Using Leave,” has been added to all of the above templates.” Source location Response from South West London and St Georges Mental Health NHS 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 Reinforce risk-assessment processes for informal patient leave.
Verbatim wording from the response “At the request, our Clinical Director for Acute and Urgent Care, Dr Razvan Gutu, described a number of immediate improvements that had already been made in response to this case. These included:” Source location Response from South West London and St Georges Mental Health NHS 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 Revise the Trust Leave Policy to strengthen leave risk assessment, multidisciplinary collaboration, safety planning and holding-power guidance.
Verbatim wording from the response “Revised Trust Leave Policy – Strengthened requirements for risk assessment, MDT collaboration, safety planning, and explicit guidance on holding powers for informal patients. This revision was approved by our Mental Health Law Group on 23 September 2025.” Source location Response from South West London and St Georges Mental Health NHS Trust
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10 Apr 2025 Jonathan Mark George Hamer · Prevention of Future Deaths report West London
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Concerns raised 5 Lack of scheduled case reviews and expected patient contact View source Failure to return or redirect incoming calls and messages View source Failure to assign priority coding to mental health cases View source Failure to provide service users and support networks with service-change information and current contact details View source Lack of cover arrangements for care co-ordinator absence View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Ensure community teams hold at least two zoning meetings each week in line with policy.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025. View source
Action
Revise case-list management when unplanned leave occurs to support continuity of care.
Status unclearThe respondent did not make the status of this action clear when they made their response on 17 April 2025. View source
Action
Conduct daily zoning, risk and care-plan reviews for unzoned, red, amber, green and otherwise enhanced-support patients, with escalation and senior oversight.
Stated completedThe respondent said that this action was complete when they made their response on 17 April 2025. View source
Action
Provide alternative team and crisis contacts through staff email footers, shared communication channels, voicemail messages and the Trust website.
Stated completedThe respondent said that this action was complete when they made their response on 17 April 2025. View source
Action
Introduce a standardised community-team huddle directive covering zoning, escalation and risk review, with implementation support and a six-month audit.
Stated completedThe respondent said that this action was complete when they made their response on 17 April 2025. View source
Action
Implement an Envoy operating procedure covering planned and unplanned staff leave, out-of-office messages and alternative contact arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 17 April 2025. View source
Action
Roll out Envoy messaging across all community teams, with monitored patient communication and absence-cover support.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025. View source
Action
Develop an NHS App and integrated patient portal with secure messaging, alerting and escalation functionality.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025. View source See 5 more actions
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AI-generated summary
Jonathan Mark George Hamer · 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
Jonathan Mark George Hamer, who had bipolar affective disorder and was receiving community mental health care, died by suicide on 24 April 2024 after going onto railway tracks in front of a train. Concerns included communication failures during care-coordinator absences, the lack of systems to redirect or action unanswered communications, and the failure to prioritise and regularly review his case.
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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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of scheduled case reviews and expected patient contact
Wider context from the report “3. Jonathan’s case was not “zoned” that is, given a priority coding on the case management system. Therefore, there was no expected period for case review or regularity of expected contact. The multi-disciplinary meetings and supervision meetings when Jonathan’s case was discussed failed to recognise and address this issue. Appropriate zoning and regular reviews are a fundamental part of mental health care and should be embedded and prioritised as part of each patient’s care planning.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to return or redirect incoming calls and messages
Wider context from the report “2. The community mental health team actively encouraged communication by text messages and emails but had no system in place to intervene when the care co-ordinator was not at work and had left no “out of office” message. There was no system to return or redirect incoming calls or messages so these remained unread and unanswered. Those initiating the communication were unaware that the information was not being received or actioned by the Trust.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign priority coding to mental health cases
Wider context from the report “3. Jonathan’s case was not “zoned” that is, given a priority coding on the case management system. Therefore, there was no expected period for case review or regularity of expected contact. The multi-disciplinary meetings and supervision meetings when Jonathan’s case was discussed failed to recognise and address this issue. Appropriate zoning and regular reviews are a fundamental part of mental health care and should be embedded and prioritised as part of each patient’s care planning.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide service users and support networks with service-change information and current contact details
Wider context from the report “1. There were communication difficulties experienced by Jonathan’s family and his supported housing with the community mental health trust responsible for his ongoing healthcare during the early part of 2024. Telephone calls and text messages were unanswered and there was no communication to confirm that in fact the care co-ordinator had a period of annual leave followed by an unplanned period of sick leave. It was unclear at inquest if service users and their support network had been provided with details of any service changes and current up to date contact details. This meant that important information was not being received by the community mental health team.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cover arrangements for care co-ordinator absence
Wider context from the report “2. The community mental health team actively encouraged communication by text messages and emails but had no system in place to intervene when the care co-ordinator was not at work and had left no “out of office” message . There was no system to return or redirect incoming calls or messages so these remained unread and unanswered. Those initiating the communication were unaware that the information was not being received or actioned by the Trust.
” 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 Ensure community teams hold at least two zoning meetings each week in line with policy.
Verbatim wording from the response “▪ Zoning Meetings: Our teams are being reviewed to ensure that they are holding a minimum of two zoning meetings per week in line with our current policy.” Source location Response from South West London and St George’s Hospitals NHS 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 Revise case-list management when unplanned leave occurs to support continuity of care.
Verbatim wording from the response “▪ A revised process for case list management when unplanned leave occurs, to ensure continuity of care.” Source location Response from South West London and St George’s Hospitals 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 Conduct daily zoning, risk and care-plan reviews for unzoned, red, amber, green and otherwise enhanced-support patients, with escalation and senior oversight.
Verbatim wording from the response “▪ Unzoned Patients: Any patient not currently assigned a zone is flagged and updated by the Team Manager and Consultant Psychiatrist, with oversight maintained via daily huddle discussions to ensure appropriate zoning is agreed and recorded. Senior Managers also complete regular reviews across the Community Service Line on teams with unzoned patients to ensure action is taken immediately.” Source location Response from South West London and St George’s Hospitals NHS 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 Provide alternative team and crisis contacts through staff email footers, shared communication channels, voicemail messages and the Trust website.
Verbatim wording from the response “▪ We have asked community teams to add specifically created email footers to their personal NHS emails to advise recipients that the mailbox may not be monitored and to provide alternative team contact details and crisis service links.” Source location Response from South West London and St George’s Hospitals 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 Introduce a standardised community-team huddle directive covering zoning, escalation and risk review, with implementation support and a six-month audit.
Verbatim wording from the response “To help embed this process consistently, we have also taken the opportunity to review and revise our team huddle agendas. A standardised huddle directive has been” Source location Response from South West London and St George’s Hospitals 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 an Envoy operating procedure covering planned and unplanned staff leave, out-of-office messages and alternative contact arrangements.
Verbatim wording from the response “▪ A new Standard Operating Procedure (SOP) for using Envoy, including cover arrangements during periods of planned and unplanned leave.” Source location Response from South West London and St George’s Hospitals 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 Roll out Envoy messaging across all community teams, with monitored patient communication and absence-cover support.
Verbatim wording from the response “The Trust has procured a digital communication system, called Envoy which enhances communication and engagement with patients. Envoy enables centralised, monitored messaging across SMS from the Trust to patients regarding appointments and provides some ability for patients to provide a SMS through to Envoy around appointments.” Source location Response from South West London and St George’s Hospitals NHS 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 Develop an NHS App and integrated patient portal with secure messaging, alerting and escalation functionality.
Verbatim wording from the response “The Trust is investing in a new digital solution centred around the NHS App and an integrated central patient portal. This initiative aims to significantly enhance communication between patients and clinical teams, thereby reducing associated safety risks. A key requirement of the project is the provision of secure messaging functionality, enabling timely, confidential communication and supporting alerting and escalation processes for patients who may be approaching crisis. The project is currently in development, with tendering underway to support NHS App integration. Completion is anticipated during 2026.” Source location Response from South West London and St George’s Hospitals NHS Trust
Open published response
12 Jul 2024 Judith Maike OBHOLZER · Prevention of Future Deaths report Inner West London
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Concerns raised 6 Lack of clarity in referral and crisis-support processes for patients receiving private and NHS treatment View source Unavailability of GP registration and contact details to medical practitioners View source Failure to share medical notes and information between private practitioners and NHS providers View source Unclear urgent and crisis referral pathways from private practitioners to NHS services View source Failure to assess NHS mental health provision independently of interim private support View source Pressure on NHS mental health services View source See 3 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
Judith Maike OBHOLZER · 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
Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.
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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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in referral and crisis-support processes for patients receiving private and NHS treatment
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS , ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of GP registration and contact details to medical practitioners
Wider context from the report “3. In the course of the evidence it was confirmed that the private consultant psychiatrist was unable to send the urgent letter to Mrs Obholzer’s GP in part because their details had not been provided . Consideration should be given to ensuring that all medical practitioners (private and NHS) can access GP registration details for patients and GP contact details to avoid delays where there is an urgent need to contact a person’s 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share medical notes and information between private practitioners and NHS providers
Wider context from the report “4. In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers . This (along with other factors) led to delays in a treatment plan being set by Wandsworth SPA as they had to obtain further details regarding Mrs Obholzer’s CBT from Mrs Obholzer rather than being able to access the notes through a shared system . Consideration should be given to ensuring a system is in place to allow the sharing of medical information between practitioners across Trusts and also between NHS and Private providers .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear urgent and crisis referral pathways from private practitioners to NHS services
Wider context from the report “2. In the course of the evidence the private consultant psychiatrist gave evidence that he was unable to refer patients directly to NHS provided crisis teams as a direct alternative to informal treatment at a private hospital. The evidence from the South West London and St George’s Mental Health Trust was that direct referrals can be made although the evidence on the exact mechanism was unclear . In Mrs Obholzer’s case, the (apparent) lack of ability of the private consultant psychiatrist to directly refer to the crisis team meant that she did not receive the community crisis support alternative to hospital admission that she required. Consideration should be given to ensuring that the pathway for urgent/crisis referrals from private practitioners to the NHS are clear to all (both for this area and throughout the country) and, if it is not already the case, to ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess NHS mental health provision independently of interim private support
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Pressure on NHS mental health services
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services . It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.
” 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 Share crisis-referral information externally through social media, website news articles, and campaign materials.
Verbatim wording from the response “Additionally, we have again shared our crisis information externally, which we do at regular intervals. This includes on social media and in extra places on our website including news articles and in information about our campaigns.” Source location Response from SW London Mental Health 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 Maintain a ratified Private Providers Shared Care Policy defining Trust and private-provider roles and responsibilities.
Verbatim wording from the response “However, in addition to the DH guidance, the Trust has a ‘Private Providers Shared Care Policy’ (Appendix 1) which was ratified in January 2024. This clearly sets out the respective roles and responsibilities of the Trust and private providers. This policy was drafted with input from Consultant Psychiatrists from a private provider and supplements the DH guidance to add specific clarity for the Trust.” Source location Response from SW London Mental Health 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 Remind staff about the Urgent Care Pathway, checking private treatment and consent, and the Private Providers Shared Care Policy through a Monthly Learning Bulletin and local GP networks.
Verbatim wording from the response “The Trust will remind all staff of the ‘Urgent Care Pathway’ in a Monthly Learning Bulletin article (to be published by October 2024). Staff will also be reminded to regularly check if service users are receiving private treatment and discuss consent to share information. Staff will also be signposted to the Trust’s ‘Private Providers Shared Care Policy’, so they are aware of the process if they are contacted by a private provider regarding a patient in crisis. This policy will also be shared through our local GP networks.” Source location Response from SW London Mental Health 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 Review and develop a consent process for recording and sharing information when patients receive both NHS and private care.
Verbatim wording from the response “However, locally the Trust is reviewing its approach to how information can be shared in line with consent and the confidentiality policy. Naturally, the Trust is not able to share clinical information with a private practitioner (and vice versa) without the explicit consent of the patient, except in rare cases where risk considerations mean information sharing is essential.” Source location Response from SW London Mental Health 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 Make the Private Providers Shared Care Policy accessible on the Trust website and communicate its existence internally and through local GP networks.
Verbatim wording from the response “The Trust accepts that this policy was not referenced and it appears there was a lack of appreciation that the policy existed during the Inquest. In response to the concern raised in the PFDR, the Trust will ensure this policy is made accessible on the Trust's website (in the GPs/Professionals section of our website) and its existence will be further communicated internally and also through our local GP networks.” Source location Response from SW London Mental Health 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 Improve and publish prominent website information directing healthcare professionals to urgent mental-health crisis referrals, including the 24/7 crisis line.
Verbatim wording from the response “In response to the PFDR, the Trust has reviewed and further improved the information available for all healthcare professionals on the Trust website to ensure it is more easily accessible. The link (button) on the front page of the website is now red to make it even more prominent and marked ‘Urgent Help’ (Home - Website (swlstg.nhs.uk)).” Source location Response from SW London Mental Health 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 Clinical information cannot ordinarily be shared between NHS and private practitioners without explicit patient consent, except where risk makes sharing essential.
Verbatim wording from the response “However, locally the Trust is reviewing its approach to how information can be shared in line with consent and the confidentiality policy. Naturally, the Trust is not able to share clinical information with a private practitioner (and vice versa) without the explicit consent of the patient, except in rare cases where risk considerations mean information sharing is essential.” Source location Response from SW London Mental Health 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 Access to GP registration and contact details is considered a national issue for the Department of Health or NHS England.
Verbatim wording from the response “The Trust does not feel able to provide a response to this aspect of the PFDR as access to GP registration details is a national issue. We understand that the response to this concern will come from the DH or NHSE response.” Source location Response from SW London Mental Health 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 National systems and guidance for information sharing between NHS and private providers are principally matters for NHS England and the Department of Health.
Verbatim wording from the response “Systems and processes for information sharing between NHS and private providers is principally a consideration for NHSE and the DH who are best placed to provide guidance around the GDPR and confidentiality considerations.” Source location Response from SW London Mental Health 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 No national or local system provides contact details for every private provider, so referral information cannot feasibly reach all providers.
Verbatim wording from the response “Unfortunately, there is currently no national or local system which enables the Trust to have the contact details of every private provider operating in its catchment area and, therefore, it is not feasible to provide information about the referral process to all these providers and those we are not aware exists. Furthermore, in Mrs Obholzer’s case, the private provider that gave evidence at the Inquest and who assessed Mrs Obholzer shortly before her death, was not based in the catchment for our Trust.” Source location Response from SW London Mental Health 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 National review of psychiatric referral pathways is considered a matter for the Department of Health and NHS England.
Verbatim wording from the response “The Trust notes the Coroner’s desire that this aspect of the PFDR is reviewed from a national perspective and considers that the DH and NHSE will be able to address this within their response.” Source location Response from SW London Mental Health 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 Private providers can refer patients directly to crisis services through the Mental Health Crisis Line, 111, 999 or A&E.
Verbatim wording from the response “However, the Trust would like to assure the Coroner that private providers can refer their patients to the Trust’s crisis services when required. Private providers can telephone or make a referral about someone they are concerned for to our crisis services via the Trust’s Mental Health Crisis Line in the same way as a GP or other non-Trust health professional. If a private provider contacts the Mental Health Crisis Line, advice will be provided, and their patient will be directed into the correct care pathway dependent upon the patient’s presentation and risk factors. In an emergency scenario, private providers can also call 999 or 111 and patients are able to attend A&E to access the pathway for crisis services.” Source location Response from SW London Mental Health Trust
Open published response
11 Jun 2024 Juan David Martin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Inadequate mental health bed capacity in London 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
Juan David Martin · 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
Juan David Martin, who had been detained under the Mental Health Act and was awaiting an appropriate mental health bed, was evacuated from a hospital assessment suite during a fire alarm and ran away. He was later witnessed allowing himself to fall from height and was confirmed deceased on 13 April 2022. The principal concern was that inadequate mental health bed capacity in London created a genuine risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health bed capacity in London
Wider context from the report “(1) Juan Martin was held informally on 7 April 2022 and following a mental health assessment on 11 April subsequently became liable for detention. He therefore spent 6 days in the Lotus Assessment Suite. Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.
(2) The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved . The Matron provided one recent example where a patient waited for 7 days in the Accident and Emergency Department for a mental health bed .
(3) The Matron added there was an exceptional process which required a considered decision at a high level to make a bed available through identifying someone currently occupying a bed space to be discharged and that the ‘flow’ of patients being discharged or moving to another setting amplified the bed capacity issue.
Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate . Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken.
” Open source report
20 Oct 2023 Michael Joseph HINDES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to refer patients to the crisis team during delays in community mental health follow-up View source Failure to make sufficient efforts to involve patients’ families in mental health care View source Delays in community mental health team follow-up View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Joseph HINDES · 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
Michael Hindes died by suicide after calling 999 because he felt suicidal and being taken to St George’s Hospital for a half-hour mental health assessment before discharge. The principal concerns were that he was not referred to the crisis team despite a likely minimum one-week wait for community mental health follow-up, and that the assessing nurse did not try to persuade him to involve his family, who were unaware of his mental ill health until after his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to the crisis team during delays in community mental health follow-up
Wider context from the report “He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen.
In the meantime, it was not thought necessary to refer him to the crisis team.
Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this.
The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services.
Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make sufficient efforts to involve patients’ families in mental health care
Wider context from the report “He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen.
In the meantime, it was not thought necessary to refer him to the crisis team.
Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this .
The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services.
Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care . In spite of the frequency of this occurrence, the lesson does not seem to be being learnt .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in community mental health team follow-up
Wider context from the report “He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made , so it was likely that Michael would have to wait an absolute minimum of a week to be seen .
In the meantime, it was not thought necessary to refer him to the crisis team.
Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this.
The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services.
Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt.
” 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 Continue participating in the national Triangle of Care initiative to strengthen engagement among patients, families, carers and professionals.
Verbatim wording from the response “We agree with your general view that challenges remain and there is a need for improvements around how to best ensure positive engagement and sharing of information between the healthcare provider, patients, and their families and carers. We are committed to the national ‘Triangle of Care’ initiative that champions the bringing together of carers and relatives, service users and professionals. It aims to promote safety, aid recovery, and sustain the wellbeing of people with mental health issues and their carers and families. This remains a key area of focus for the Trust. The Psychiatric Liaison Team continue to reflect on this and will be changing their local” Source location Response from South West London and St George's Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and issue a Monthly Learning Bulletin article reminding Trust staff how to hold meaningful conversations about sharing information with families and document them.
Verbatim wording from the response “As per your request with the PFD to raise awareness of this area, we will take the opportunity to raise awareness within the Trust via a specific newsletter article issued to Trust staff (known as our Monthly Learning Bulletin) to remind and promote how and when to best ensure there are meaningful conversations with patients around sharing information with families. This will focus on the Triangle of Care approach and provide clarity around the delicate balance between encouraging patients whilst respecting their wishes and ensuring this is clearly documented. This will be developed and issued by March 2024.” Source location Response from South West London and St George's Mental Health
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 Change Psychiatric Liaison Team local protocols to strengthen prompts reminding clinicians how to approach information sharing and family engagement.
Verbatim wording from the response “We agree with your general view that challenges remain and there is a need for improvements around how to best ensure positive engagement and sharing of information between the healthcare provider, patients, and their families and carers. We are committed to the national ‘Triangle of Care’ initiative that champions the bringing together of carers and relatives, service users and professionals. It aims to promote safety, aid recovery, and sustain the wellbeing of people with mental health issues and their carers and families. This remains a key area of focus for the Trust. The Psychiatric Liaison Team continue to reflect on this and will be changing their local” Source location Response from South West London and St George's Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient had capacity and refused family information-sharing, so disclosure without consent would have been unlawful, although further exploration was warranted.
Verbatim wording from the response “The clinical assessment clearly concluded that the patient had capacity to make decisions and the assessing nurse was of the firm view that he was clear that he did not consent to information being shared with his family around his mental health and struggles.” Source location Response from South West London and St George's Mental Health
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 Clinical assessment found low self-harm risk, so discharge with routine CMHT referral rather than crisis services was considered appropriate.
Verbatim wording from the response “As you are aware through the Inquest, the clinical risk assessment undertaken at the time by the assessing nurse in the Psychiatric Liaison Team deemed the patient to be of low risk of self-harm and that he was suitable to be discharged home. In addition, with a routine referral to the Community Mental Health Team (CMHT) for ongoing diagnosis/further assessment, as crisis services were not required at that time.” Source location Response from South West London and St George's Mental Health
Open published response
22 Jul 2022 Christopher Thomas Ace Ryan · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to consider and approve or refuse patients' escorted leave requests View source Blurring of the boundaries between escorted leave intentions and ward staff's ability to facilitate therapeutic leave View source An unsecured car park open to the road View source Failure of clinical staff to be aware of escorted leave boundary blurring View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Thomas Ace Ryan · 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
Christopher Thomas Ace Ryan was detained under section 3 of the Mental Health Act and absconded from escorted leave on 23 December 2020. He obtained and smoked heroin, developed laboured breathing, lost consciousness, and died despite CPR. Concerns included repeated absconding during escorted leave, access to illicit drugs, unclear boundaries around escorted leave, and the security and smoking arrangements at the hospital car park.
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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and approve or refuse patients' escorted leave requests
Wider context from the report “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused . Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Blurring of the boundaries between escorted leave intentions and ward staff's ability to facilitate therapeutic leave
Wider context from the report “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients , and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation An unsecured car park open to the road
Wider context from the report “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical staff to be aware of escorted leave boundary blurring
Wider context from the report “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this . Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
” 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 Facilitate escorted leave according to documented staffing stipulations and address non-compliance with applicable staff.
Verbatim wording from the response “We recognise that understanding of Covid and the applicable restrictions have reduced significantly over time. Despite this, we have taken on board the spirit of the concerns raised and will review our leave form / guidance to help ensure we better capture any stipulations around staffing of escorts. Leave will be facilitated in accordance with these stipulations and non-compliance with be addressed accordingly with the applicable members of staff.” Source location Response from South West London and St George's Mental Health
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 Review the section 17 leave form and guidance to capture escort staffing stipulations.
Verbatim wording from the response “We recognise that understanding of Covid and the applicable restrictions have reduced significantly over time. Despite this, we have taken on board the spirit of the concerns raised and will review our leave form / guidance to help ensure we better capture any stipulations around staffing of escorts. Leave will be facilitated in accordance with these stipulations and non-compliance with be addressed accordingly with the applicable members of staff.” Source location Response from South West London and St George's Mental Health
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 Share learning from the Inquest across the service line.
Verbatim wording from the response “From a holistic perspective, ward staff have conversations with patients about how they intend to use their leave and how best they can be supported. Being able to complete daily living activities such as going shopping, viewing properties that patients may live in post discharge and attending appointments are seen as part of the patient’s recovery journey; ward staff often support patients through escorted leave to achieve these recovery goals. This is now greatly aided by the relaxation of the Covid Restrictions. Going forward the Trust will continue to observe any further restrictions should they return, in order to protect its service users, its staff and the public. The learning arising from this Inquest has been shared across the service line.” Source location Response from South West London and St George's Mental Health
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 Responsibility for the unsecured car park rests with St George’s University Hospital NHS Foundation Trust, which owns and runs it.
Verbatim wording from the response “The car park is not owned or run by this Trust. This car park is on the Queen Mary’s Hospital site, which is owned and run by St George’s University Hospital NHS Foundation Trust (SGH). I can confirm that the Queen Mary’s Hospital site is a non-smoking site and is covered by the SGH ‘Smokefree Policy’, which specifically mentions the Queen Mary’s Hospital site, where smoking is not permitted and our policy is the same for all our sites, where smoking is not permitted anywhere on our grounds (see below).” Source location Response from South West London and St George's Mental Health
Open published response
28 Sep 2017 GILLIAN O’KEEFFE · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 5 Unlikelihood of self-referral by patients unable to engage with mental health services View source Inappropriate discharge of patients in greatest need of mental health support for non-engagement View source Failure to coordinate pre-discharge handover and transition with the GP surgery View source Lack of an accessible mechanism for families to share mental health concerns with the professional team View source Lack of a procedure for following up urgent GP concerns or referrals 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
GILLIAN O’KEEFFE · 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
Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.
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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unlikelihood of self-referral by patients unable to engage with mental health services
Wider context from the report “(2) In view of her history and the inability of the Trust or GP surgery to make contact with Mrs O’Keeffe it was highly unlikely that she would self-refer .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate discharge of patients in greatest need of mental health support for non-engagement
Wider context from the report “(1) That the decision to discharge Mrs O’Keeffe ‘for non-engagement’ from the local Mental Health NHS Foundation Trust care in January 2017 appeared illogical when it was likely, having regard to the facts, that she was in greatest need of their help : she was a service user of long standing, she had an acute deterioration in her mental state in March 2016, that there had been concerns raised by her family in October 2016 and that no professionals had been able to make visual contact with her since October 2016.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate pre-discharge handover and transition with the GP surgery
Wider context from the report “(3) There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge nor attempt to ensure that there was a seamless transition to the GP surgery .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an accessible mechanism for families to share mental health concerns with the professional team
Wider context from the report “(5) There appeared no easy or appropriate way that the family were able to share information and their concerns about Mrs O’Keeffe’s mental health with the professional team , consequently, notwithstanding the family’s continual and concerted attempts to notify Mrs O’Keeffe’s care co-ordinator, they felt that the professionals were unaware of the parlous state of Mrs O’Keeffe’s mental health and the family’s serious concerns .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for following up urgent GP concerns or referrals
Wider context from the report “(4) Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up GP concerns or referrals particularly where there was likely to be a degree of urgency .
” 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 Reinforce use of the Trust-approved crisis-plan template with staff through governance meetings and learning dissemination, with inclusion in clinical audits.
Verbatim wording from the response “The importance of sending the Trust approved template for a crisis plan to GPs will be re-enforced to staff through team and local governance meetings and via the Trust’s dissemination of learning mechanisms such as the monthly bulletin, etc. This will again form part of the clinical audit cycle. The importance of family liaison and engagement forms part of our triangle of care programme. This programme is just about to start its round of ‘self-assessments’ and with the community services this learning will be cascaded through this process.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-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 Formalise guidance for GPs on raising urgent concerns and referrals with lead CCG involvement.
Verbatim wording from the response “The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns they may have. The Trust is in the process of formalising this with the lead CCG GP involvement. It will be shared with GP colleagues once it has been signed off.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade learning from triangle-of-care self-assessments to community services to strengthen family liaison and engagement.
Verbatim wording from the response “The importance of sending the Trust approved template for a crisis plan to GPs will be re-enforced to staff through team and local governance meetings and via the Trust’s dissemination of learning mechanisms such as the monthly bulletin, etc. This will again form part of the clinical audit cycle. The importance of family liaison and engagement forms part of our triangle of care programme. This programme is just about to start its round of ‘self-assessments’ and with the community services this learning will be cascaded through this process.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Clinical Disengagement/Did Not Attend Policy to require GP engagement before discharge and audit adherence.
Verbatim wording from the response “We have provided rationale for the decision to discharge but also acknowledge that more engagement should have taken place with key stakeholders prior to Mrs O’Keefe’s discharge. Since this incident, our Clinical Disengagement/Did Not Attend Policy has been updated. The updated version is more prescriptive with regards to what actions need to be taken before a patient can be discharged and this includes engagement with the GP and inclusion of the GP in the decision to discharge. Adherence to this policy is audited through our clinical audit programme.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scope a CPA quality-improvement project focused on family and carer engagement and liaison with primary care.
Verbatim wording from the response “The Trust was disappointed to learn that the family felt that there wasn’t an easy way to share information and their concerns about Mrs O’Keefe with the team. The Clinical Director is currently scoping a quality improvement project in relation to Care Programme Approach (CPA) focussing on the engagement of families/carers and liaison with primary care. In addition to this, the Head of Nursing for the service is organising a learning event so that each of the actions identified in the plan can be shared with the team, with the event providing an opportunity for reflection and learning. As referred to earlier the trust is also committed to the triangle of care principles and is just about to undertake the next round of self-assessments.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-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 Share the formalised GP concerns and referrals guidance with GP colleagues after sign-off.
Verbatim wording from the response “The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns they may have. The Trust is in the process of formalising this with the lead CCG GP involvement. It will be shared with GP colleagues once it has been signed off.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce GP involvement in discharge decisions through governance meetings and learning dissemination, with reinforcement through the clinical audit cycle.
Verbatim wording from the response “The Trust’s revised Clinical Disengagement/Did Not Attend Policy states that the team should liaise with the GP and invite them to be involved in the decision to discharge the patient.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake the next round of triangle-of-care self-assessments.
Verbatim wording from the response “The importance of sending the Trust approved template for a crisis plan to GPs will be re-enforced to staff through team and local governance meetings and via the Trust’s dissemination of learning mechanisms such as the monthly bulletin, etc. This will again form part of the clinical audit cycle. The importance of family liaison and engagement forms part of our triangle of care programme. This programme is just about to start its round of ‘self-assessments’ and with the community services this learning will be cascaded through this process.” Source location 2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
Open published response
14 Dec 2016 Jaroslaw Rogala (otherwise known as Jarek) · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Lack of inpatient facilities for admitting patients with addiction for care and supervision during crisis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jaroslaw Rogala (otherwise known as Jarek) · 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
Jaroslaw Rogala, also known as Jarek, was found deceased by hanging in his bedroom on 3 September 2016 after experiencing suicidal ideation while intoxicated with alcohol. The report raised concern that patients with addiction at risk of suicide may have no inpatient facility available for care and supervision during a crisis.
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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient facilities for admitting patients with addiction for care and supervision during crisis
Wider context from the report “That those patients with addiction are risk of suicide as there are no in-patient facilities to admit them for care and supervision when in crisis in circumstances as described in this case.
” 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 Offer higher-risk consenting patients transfer to the Lotus Psychiatric Decision Unit for up to 48 hours of support, monitoring and extended assessment.
Verbatim wording from the response “In fact, with the support of our Commissioners, local services for patients in mental health crisis have improved since the time of Mr Rogala’s contact with our services, and this may provide you with further reassurance. Since November 2016, clinicians working in the Trust’s Emergency and Urgent Mental Health Services (including Liaison Psychiatry and Home Treatment teams) have been able to offer higher risk consenting patients the option of transfer to the Lotus Psychiatric Decision Unit (PDU). The Lotus suite enables patients to be supported and monitored for up to 48 hours in a dedicated safe space at Springfield University Hospital and permits an extended assessment to be undertaken. The outcome of this could indicate a formal admission to an acute psychiatric ward, or some other form of support.” Source location 2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that addiction-related crisis patients are discriminated against or lack access to a safe place under existing service criteria.
Verbatim wording from the response “From our consideration of the case and the criteria of existing services we therefore do not believe that patients with an addiction are discriminated against when a co-existing mental health crisis, such as suicidal ideation, is identified. Where significant risk is indicated, the use of the Mental Health Act may also be considered to ensure a patient is conveyed to a place of safety for an assessment even when they are not agreeable. However, the use of the Mental Health Act was not an option in the case of Mr Rogala as his risk was not determined to be high at the time of assessment; he had a primary dependence on alcohol which is an exclusion under the Mental Health Act; and he had capacity to make decisions himself.” Source location 2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-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 Existing local crisis services provide appropriate assessment, support and potential inpatient admission for patients with addiction and suicidal thoughts.
Verbatim wording from the response “The possibility of a gap in service provision has been considered in the event of the circumstances of the case being different, for example: if Mr Rogala had been assessed as suicidal in the context of alcohol dependence or be requesting admission to hospital. If this had been the case, psychiatric liaison services would have explored a range of options with the aim of the risk of him acting on his thoughts being alleviated. This may have led to a referral to the home treatment service which is able to provide intensive support for people who are suicidal, regardless of the presence of alcohol or any other form of addiction.” Source location 2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-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 Clinical commissioning groups are responsible for commissioning the full range of local mental health and substance misuse services.
Verbatim wording from the response “Our deepest sympathies are extended to the family and friends of Mr Rogala. The conclusion that we have reached indicates there is no current gap in services that would have prevented him accessing a safe place, and the criteria for accessing crisis support from mental health services do not discriminate against those patients who are in crisis due to the presence of an addiction, other than the statutory exclusions written into the Mental Health Act. In discussion with CCG commissioners who are the responsible body for commissioning a full range of services, including mental health and substance misuse services, the Trust also believes the framework of services within Wandsworth and Merton to be in line with arrangements in other parts of London, and consistent with the overall national picture.” Source location 2016-0445-Response-by-South-West-London-and-St-Georges-Mental-Health-NHS-Trust
Open published response
2 Jul 2014 Liam Hardy · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure of the electronic patient record system to flag or summarise significant events and primary concerns in a single place View source Insufficient time to read all patient notes before assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Liam Hardy · 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
Liam Hardy, a 15-year-old schoolboy, died after tying his school tie around his neck at his grandfather’s home on 19 November 2012. The inquest recorded concerns that his complex behavioural and emotional problems were not adequately assessed or managed, that information was not fully shared or accessed, and that the risks associated with self-harm were not adequately managed. A further concern was that the electronic patient record system did not clearly flag or summarise significant events and primary concerns for clinicians.
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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic patient record system to flag or summarise significant events and primary concerns in a single place
Wider context from the report “The nurse who assessed Liam after an episode of self harm was unaware of some of the significant events in Liam’s history. She explained that the RiO system (an electronic patient record system used in many Trusts) did not flag up or summarise such events or primary concerns and issues in a single place , and there was insufficient time to read all of the notes (which might be voluminous) before seeing a patient. Had she been aware of the full history her actions may have been different in Liam’s case, but her comments about the RiO system were general, and the difficulties are apparently encountered even today .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient time to read all patient notes before assessment
Wider context from the report “The nurse who assessed Liam after an episode of self harm was unaware of some of the significant events in Liam’s history. She explained that the RiO system (an electronic patient record system used in many Trusts) did not flag up or summarise such events or primary concerns and issues in a single place, and there was insufficient time to read all of the notes (which might be voluminous) before seeing a patient . Had she been aware of the full history her actions may have been different in Liam’s case, but her comments about the RiO system were general, and the difficulties are apparently encountered even today .
” Open source report
15 Apr 2014 Mr Philip Anthony Dean · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Insufficient HHT funding for continuity of care and named designated workers View source Failure of the SUI report to identify all matters in issue View source Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section View source Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel View source Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians View source Discharge-dependent referral to psychology leaving patients without ongoing support 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
Mr Philip Anthony Dean · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient HHT funding for continuity of care and named designated workers
Wider context from the report “(1) That the HHT is not sufficiently funded to allow continuity of care and named designated workers .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the SUI report to identify all matters in issue
Wider context from the report “(6) That The SUI report missed all matters in issue in this case .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section
Wider context from the report “(4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance , despite explicit referral for the same from the doctor who knows him best.
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of HTT and liaison psychiatry services with medically qualified personnel
Wider context from the report “(5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel , and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians
Wider context from the report “(3) That liaison psychiatry does not record pertinent information such as GP recommends section , thus denying those coming after the benefit of the GP’s professional opinion .
” 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 South West London and St George'S Mental Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge-dependent referral to psychology leaving patients without ongoing support
Wider context from the report “(2)That discharge from the HTT is required before referral to psychology can be made , leaving patients without ongoing support in the interim .
” 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 Commence a named-worker pilot for Home Treatment Team service users and review it after six months.
Verbatim wording from the response “The Mental Health Implementation Guide suggests that HTT’s should provide a designated named worker, responsible for coordinating service users care, providing continuity of care, ensuring effective communication within the team and acting as a contact point for both service users and Carers. Although there are a number of practical issues that currently impact on the HTT’s ability to operate a system of designated workers, a pilot will be commenced, taking the learning from other HTT’s nationally, and reviewed in six months.” Source location 2014-0172-Response
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 Recruit nursing staff and increase the Wandsworth Home Treatment Team nursing establishment using allocated investment.
Verbatim wording from the response “In terms of funding the HTT has been identified as being under resourced based on the expected number of contacts for the teams caseload and the number of crisis episodes which are expected to be completed per month. A Trust wide Acute Care Pathway Project, undertaken in March 2014 identified that Wandsworth HTT was under established by 3 Whole Time Equivalent (WTE) of nursing staff. Furthermore, the project identified that Wandsworth HTT took over the management of the Trust’s Crisis line in approximately 2009 without additional resource being provided equating to 2 additional WTE of nursing staff required. Medical staffing in HTT was not identified as a concern.” Source location 2014-0172-Response
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 Commission externally led training workshops on serious-incident investigations, report writing and quality assurance.
Verbatim wording from the response “As a Trust we have learnt from this and as a result of a review of our serious incident procedures, initial findings from concise investigations are reviewed after ten working days so that the level of complexity can be considered and the case escalated to the level of a comprehensive investigation if necessary. All comprehensive investigations are led by an experienced clinician, quality assured by the Serious Incident Lead Investigator, signed off by a Board member and agreed with the Clinical Commissioning Groups. The Trust has commissioned externally led training workshops to develop knowledge, skills and quality assurance processes for investigations and report writing.” Source location 2014-0172-Response
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 Review initial findings from concise serious-incident investigations after ten working days and escalate cases when necessary.
Verbatim wording from the response “As a Trust we have learnt from this and as a result of a review of our serious incident procedures, initial findings from concise investigations are reviewed after ten working days so that the level of complexity can be considered and the case escalated to the level of a comprehensive investigation if necessary. All comprehensive investigations are led by an experienced clinician, quality assured by the Serious Incident Lead Investigator, signed off by a Board member and agreed with the Clinical Commissioning Groups. The Trust has commissioned externally led training workshops to develop knowledge, skills and quality assurance processes for investigations and report writing.” Source location 2014-0172-Response
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 Liaison Psychiatry under-resourcing is primarily a matter for the Trust’s commissioners, not internal Trust resource allocation.
Verbatim wording from the response “The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels. In this regard, so are the majority of Liaison Psychiatry departments, and the under-resourcing is a matter primarily for the Trust’s commissioners, rather than a problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted. An experienced and competent Band 7 nurse will do a much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on a par with a senior doctor’s. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided a Coroner with data which showed a low” Source location 2014-0172-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The implication that only medically qualified staff can make accurate Liaison Psychiatry assessments is not accepted.
Verbatim wording from the response “The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels. In this regard, so are the majority of Liaison Psychiatry departments, and the under-resourcing is a matter primarily for the Trust’s commissioners, rather than a problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted. An experienced and competent Band 7 nurse will do a much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on a par with a senior doctor’s. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided a Coroner with data which showed a low” Source location 2014-0172-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A mental health assessor may reasonably reach a different conclusion from the GP because risk changes rapidly and requires current assessment.
Verbatim wording from the response “It is expected that the Liaison Psychiatry team do record pertinent information in the electronic patient record and that all documentation from referrers is uploaded and available on this system. It is expected that staff read all relevant documentation when making an assessment. It is with regret that the information from the GP was not passed appropriately, however risk is a factor that shifts and changes and each assessment will include a new and up to date risk evaluation, based upon the person’s current situation. As a result of the assessment made, an appropriate decision was taken to admit Mr Dean. As risk can change very rapidly, it is possible that the mental health assessor may come to a different conclusion to that recommended by the GP.” Source location 2014-0172-Response
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 Liaison Psychiatry staff are experienced and trained, so the available assessment was considered the most appropriate despite no guaranteed 24/7 Section 12 assessment.
Verbatim wording from the response “It has not been possible to identify any Accident and Emergency Department which runs a psychiatry service that has 24 hour 7 day a week presence of Section 12 approved doctors, and none where the Section 12 doctor would always do the assessment at first instance, unless the patient were being assessed in a police cell. Therefore it appears that Mr Dean received the most appropriate assessment available and this is comparable to other psychiatric services available elsewhere. The staff in Liaison Psychiatry are very experienced in carrying out mental health assessments and receive extensive training and ongoing supervision.” Source location 2014-0172-Response
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 Temporary whole-team care coordination is the current arrangement for HTT service users without an existing Care Coordinator.
Verbatim wording from the response “The Trust is committed to ensuring continuity of care for service users and although it is not within the Trust’s current Operational Policy for HTT’s to work with designated workers the policy does state that service users accepted for home treatment, who have been newly referred or re-referred to Mental Health Services and so do not have an existing Care Coordinator, will be temporarily care coordinated within the team, in the context of a whole team approach.” Source location 2014-0172-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations