Concerns raised 3 Lack of communication and engagement between agencies involved in Ollie’s care View source Failure to act on Ollie’s stated pronoun preference View source Failure to record important discussions between early help and the school View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ollie Lee · 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
Ollie Lee, who had a history of suicidal thoughts and self-harm, died by suicide on 6 October 2024. The principal concerns were poor communication and engagement between the agencies involved, including failures to share information about self-harm and CAMHS discharge, which resulted in missed opportunities for continued mental health support. Important discussions about Ollie’s preferred name and pronouns were also not recorded or acted upon.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication and engagement between agencies involved in Ollie’s care
Wider context from the report “1) Poor communication and engagement between the agencies involved with Ollie including her school, CAMHS and targeted early help.
2) A lack of communication and engagement between targeted early help and CAMHS despite both agencies being aware that the other was involved. This led to a confusing picture and a missed opportunity for Ollie to remain open to CAMHS and receive psycho social intervention and continued support from CAMHS.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on Ollie’s stated pronoun preference
Wider context from the report “3) There was no record of important discussions that occurred between early help and the school and Ollie’s preference in relation to pronouns was not acted upon .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record important discussions between early help and the school
Wider context from the report “3) There was no record of important discussions that occurred between early help and the school and Ollie’s preference in relation to pronouns was not acted upon.
” 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 Meet with Targeted Early Help senior management to explore improved joint working and timely information sharing.
Verbatim wording from the response “On 8 June 2026, the General Manager for Barnsley CAMHS met with the Service Manager for the Targeted Early Help Service (TEHS) to explore opportunities for improving joint working and strengthening timely and effective information sharing between services. To further improve communication between CAMHS and TEHS, three key actions were agreed for initial implementation:” Source location Response from South West Yorkshire Partnership 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 Hold bi-monthly strategic reviews of CAMHS and Targeted Early Help joint working and consider developing a Memorandum of Understanding.
Verbatim wording from the response “• Bi-monthly strategic review
The TEHS Service Manager and the CAMHS General Manager will meet on a bi-monthly basis to review progress, evaluate the effectiveness of joint working arrangements, and consider the development of a Memorandum of Understanding (MoU). This will be informed by learning from these initial actions.” Source location Response from South West Yorkshire Partnership 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 Provide Barnsley CAMHS training on information sharing and multi-agency working.
Verbatim wording from the response “Having identified local learning from the case note review related to multi-agency communication and engagement, on 4 April 2025, training was provided to Barnsley CAMHS by the Trust Safeguarding Children Team on Information Sharing and Multi-Agency Working. The purpose of the training was to reinforce the importance of multi-agency working and information sharing to promote best practice. The Trust also has a Safeguarding toolkit which supports clinical staff on a range of practice areas including information sharing, and quality and accuracy of documentation.” Source location Response from South West Yorkshire Partnership 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 Train Targeted Early Help practitioners on CAMHS referrals and access to children’s mental health support.
Verbatim wording from the response “Having identified learning related to multi agency communication and engagement in the case note review, on 28 January 2025 the Branching Minds Clinical Lead delivered training to Targeted Early Help Practitioners, who are children’s social care employees, in relation to the CAMHS referral process and access to mental health support for children and young people. The purpose of the training was to reinforce the multi-agency arrangements and set a clear expectation that communication between practitioners is active, timely, and accountable. This training is scheduled to be repeated in August 2026. In recognition of potential staff turnover within children’s social care, the Trust will be providing these training sessions annually, supported by additional sessions to be arranged at the request of social care services.” Source location Response from South West Yorkshire Partnership 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 Embed clinical frameworks covering the child’s voice, consent, engagement, crisis, discharge planning and risk assessment.
Verbatim wording from the response “A Patient Safety Improvement Plan to address the system-based learning was developed and overseen by the CYPMHS PSOG. The Patient Safety Improvement Plan focused on embedding the use of the clinical frameworks that are in place within the Trust to support practice, including: Capturing the Childs Voice; the Consent to Care, Treatment & Discharge tool and Engagement & Communication of Care; and Crisis, Discharge Planning and Risk Assessment. The completion of the Patient Safety Improvement Plan actions was approved by the CYPMHS PSOG in October 2025.” Source location Response from South West Yorkshire Partnership 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 Consider a collaborative Trust and partner-agency response to the Act’s information-sharing provisions.
Verbatim wording from the response “Finally, in April 2026 the Children’s Wellbeing and Schools Act 2026 received royal assent, and this includes the statutory duty for partner agencies to share information relevant to safeguarding and promoting the wellbeing of children and young persons. This statutory duty is intended to apply from September 2026 and national guidance to support its implementation is in consultation process. We are currently considering this within the Trust and with partner agencies to ensure a collaborative and robust response to the information sharing provisions of the Children’s Wellbeing and Schools Act 2026.” Source location Response from South West Yorkshire Partnership 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 Establish daily Targeted Early Help attendance at the Branching Minds briefing.
Verbatim wording from the response “• Daily briefing attendance
A representative from the Targeted Early Help Service will join the existing daily briefing at Branching Minds. This will enable TEHS to share relevant information about children and young people (CYP) known to their service and facilitate timely consultation with the crisis team where required.” Source location Response from South West Yorkshire Partnership 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 Complete local actions addressing information sharing and multi-agency discharge planning.
Verbatim wording from the response “The case note review identified areas of learning local to Barnsley CAMHS, including Information Sharing and Multi Agency Discharge Planning; the clinical quality of the Risk Assessment for Non-Engagement form (RANE); and the associated discharge processes. The local actions were completed by June 2025” Source location Response from South West Yorkshire Partnership NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide annual Targeted Early Help training, with additional sessions arranged at social care’s request.
Verbatim wording from the response “Having identified learning related to multi agency communication and engagement in the case note review, on 28 January 2025 the Branching Minds Clinical Lead delivered training to Targeted Early Help Practitioners, who are children’s social care employees, in relation to the CAMHS referral process and access to mental health support for children and young people. The purpose of the training was to reinforce the multi-agency arrangements and set a clear expectation that communication between practitioners is active, timely, and accountable. This training is scheduled to be repeated in August 2026. In recognition of potential staff turnover within children’s social care, the Trust will be providing these training sessions annually, supported by additional sessions to be arranged at the request of social care services.” Source location Response from South West Yorkshire Partnership 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 Establish fortnightly CAMHS and Targeted Early Help case review meetings for coordinated working.
Verbatim wording from the response “• Fortnightly case review meeting
An initial fortnightly meeting will be established between CAMHS and TEHS, attended by a CAMHS Team Manager and a TEHS Team Manager, to review cases awaiting allocation or intervention. This will support information sharing and identify opportunities for coordinated or joint working.” Source location Response from South West Yorkshire Partnership 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 Barnsley Metropolitan Borough Council is the lead agency for the wider Barnsley Children’s Reform Agenda response.
Verbatim wording from the response “All children’s services, including CAMHS, are involved in the broader Children’s Reform Agenda, which is a comprehensive plan aimed at transforming children’s social care and child protection policy, with a focus on improving multi-agency collaboration and enabling earlier, more effective support for children and families. BMBC are the lead agency of the wider Barnsley children’s services response to the Children’s Reform Agenda, and the Trust are committed to supporting the multi-agency response to the Children’s Reform Agenda. We understand BMBC have included a number of the initiatives, or proposed plans, in their response to the Regulation 28 report.” Source location Response from South West Yorkshire Partnership NHS Trust
Open published response
9 Apr 2026 Richard Mark WHELAN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Failure to devise a plan for taking forward referrals before completion of triage View source Failure to require referrals to SPA from people with mental health experience View source Delays in triaging non-urgent SPA referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Mark WHELAN · 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
Richard Mark Whelan died on 15 December 2024 from exsanguination caused by incised wounds to both wrists after a deliberate act intended to end his life. In the preceding weeks, his mental health had deteriorated, and a referral to the Mental Health Trust Single Point of Access made on 11 December had not been acted on by the time of his death. The principal concern was that non-urgent referrals could take up to 14 days to be triaged, with a further plan only devised after triage.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to devise a plan for taking forward referrals before completion of triage
Wider context from the report “Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage reflecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require referrals to SPA from people with mental health experience
Wider context from the report “Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage reflecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in triaging non-urgent SPA referrals
Wider context from the report “Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage reflecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral.
” 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 Amend the referral form to direct referrers with positive risk-question responses to contact SPA immediately about the referral.
Verbatim wording from the response “The Trust accepts referrals from a wide range of agencies and professionals and also from individuals, their families and carers. In respect of referrals received from referrers with limited understanding of mental health conditions, the Trust is developing referral guidance to support referrers in recognising risk factors and understanding when immediate telephone contact with SPA is required. In addition, the referral form is being amended to include guidance that, where there are positive responses to risk” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop referral guidance to help referrers recognise risk factors and identify when immediate telephone contact with SPA is required.
Verbatim wording from the response “The Trust accepts referrals from a wide range of agencies and professionals and also from individuals, their families and carers. In respect of referrals received from referrers with limited understanding of mental health conditions, the Trust is developing referral guidance to support referrers in recognising risk factors and understanding when immediate telephone contact with SPA is required. In addition, the referral form is being amended to include guidance that, where there are positive responses to risk” Source location Response from South West Yorkshire Partnership NHS Foundation 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 Universal screening and urgency-based assessment are considered sufficient to align care with the severity and immediacy of each mental health presentation.
Verbatim wording from the response “The Trust’s current process is that all referrals are screened by a registered Single point of Access (SPA) practitioner within 48 hours. This process considers the content of the referral, including any risk information provided, together with relevant information available on the Trust's clinical systems or elsewhere in order to determine the appropriate level of urgency and care pathway. For those identified as urgent through the screening process, assessment takes place within 24 hours. For those referrals identified as routine, assessment takes place within 14 days. The universal screening process therefore ensures that individuals receive care aligned with the severity and immediacy of their mental health presentation.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
Concerns raised 3 Failure to use a sufficiently assertive approach to engage people with deteriorating mental health, including in complex cases View source Inadequate liaison between police and enhanced community mental health teams when people are in custody View source Lack of mandatory training for all staff on the effect of substance misuse on mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Claire Louise Driver · 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
Claire Louise Driver had a history of schizoaffective disorder and polysubstance misuse and was found in significant decomposition in a shallow stream on 14 September 2024 after being reported missing on 24 June 2024. The cause of death was unascertained. The inquest heard concerns about limited attempts to engage her while her mental health was deteriorating, liaison between police and mental health services, and staff training on substance misuse and mental health.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South West Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a sufficiently assertive approach to engage people with deteriorating mental health, including in complex cases
Wider context from the report “(1) The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating .
It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody.
A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate liaison between police and enhanced community mental health teams when people are in custody
Wider context from the report “(1) The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating.
It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody .
A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory training for all staff on the effect of substance misuse on mental health conditions
Wider context from the report “(2) The inquest heard that training on the effect of substance misuse on mental health conditions is not mandatory for all staff and would be of assistance when caring for patients such as Claire.
” 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 Pilot a caseload-management tool requiring enhanced-team cases to be discussed with clinical leads or team managers and recording contacts, attempted contacts and meetings.
Verbatim wording from the response “To support the consistent implementation of FACT and the intensive and assertive approach to care, a caseload management tool is currently being piloted that will provide assurances that all service users within the Enhanced Team are discussed with a relevant clinical lead/team manager. This will ensure that clinicians receive additional case management support and ensure that all contacts, attempted contacts, and meetings are recorded within the notes, and that those who meet the criteria for benefiting from a more assertive approach are consistently identified and supported.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide co-occurring mental-health and substance-misuse training as an essential-to-role course for relevant staff, identifying completion through supervision or appraisal and recording it in training records.
Verbatim wording from the response “Working with people with co-existing mental health problems and substance misuse issues has been included as a priority area of the mental health care group’s Learning Needs Analysis, which forms the basis of the training programme for all staff. Public Health England have made available an eLearning course – Better Care for people with co-occurring mental health and alcohol/drug use conditions, which has been made available to Trust staff. This is” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify service users requiring intensive or assertive support and ensure they receive the appropriate level of care.
Verbatim wording from the response “As part of this review process the Trust established a working group to work across the whole of the organisation. This review focused on provisions available to our Enhanced teams, who deliver care to those with the most complex needs in the community whose care can involve a variety of agencies. This work is on-going. Those requiring intensive and assertive support have been identified within our teams and we have ensured they have the correct level of care.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an organisation-wide review of intensive and assertive community support provision through an established working group.
Verbatim wording from the response “In July 2024 NHS England (NHSE) began a review of the intensive and assertive community support available for those with serious mental health disorders, with Integrated Care Boards across the country reviewing current staffing provisions and numbers of service users who would access such services. NHSE are leading integrated care boards (ICBs) and other organisations in reviewing service delivery for people who require intensive and assertive community support, and we anticipate the publication of service standards for us to implement later this summer.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop enhanced-team oversight of intensive and assertive care journeys, including clinical scrutiny of discharge planning, risk assessments and care plans.
Verbatim wording from the response “The enhanced teams are now working to develop a greater understanding of those service users who require an intensive and assertive approach. This gives greater ability for teams and leaders to follow the care journey for these services users and add clinical scrutiny and assurance as part of discharge planning, to ensure safe oversight and discharge with up-to-date risk assessments and care plans.” Source location Response from South West Yorkshire Partnership NHS Foundation 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 Targeted training arrangements ensure staff who require substance-misuse training receive it, so mandatory training for all staff is not necessary.
Verbatim wording from the response “Working with people with co-existing mental health problems and substance misuse issues has been included as a priority area of the mental health care group’s Learning Needs Analysis, which forms the basis of the training programme for all staff. Public Health England have made available an eLearning course – Better Care for people with co-occurring mental health and alcohol/drug use conditions, which has been made available to Trust staff. This is” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
Concerns raised 3 Failure to provide families with advice on available options when concerned for a family member's safety View source Failure to consider alternative services when BSARC is unavailable View source Unavailability of services that can be called to discuss a person's mental state View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rachel Louise MORTIMER · 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
Rachel Louise Mortimer took her own life on 25 June 2023 by hanging, following previous overdoses and a recent episode involving overdose and an attempt to hang herself. The report identified concerns that family and paramedics were not given advice about available support or emergency options, and that no alternative service was arranged after a planned risk-mitigation referral was unavailable.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with advice on available options when concerned for a family member's safety
Wider context from the report “1. Following concerned calls by family no advice was provided on what options were available to them if they were concerned for their family members safety and no provision of services that could be called to discuss her mental state.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South West Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative services when BSARC is unavailable
Wider context from the report “2. Despite identifying the risk of emotional dysregulation and that BSARCS would mitigate this risk. When IHCBTT were informed BSARC was not available no further consideration was given to any other service to minimise the risk .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of services that can be called to discuss a person's mental state
Wider context from the report “1. Following concerned calls by family no advice was provided on what options were available to them if they were concerned for their family members safety and no provision of services that could be called to discuss her mental state .
” 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 the concern with Barnsley IHBT practitioners and reinforce routine use of the resource pack when advising families about safety and wellbeing support.
Verbatim wording from the response “Your concern will be shared with all practitioners in Barnsley IHBT through team meetings and email communication. This will include an emphasis on the importance of practitioners always referring to the resource pack, to ensure the most appropriate advice is provided to service users and their families about how to access support at all times should they have concerns about their loved one’s safety and wellbeing.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Barnsley IHBT to reconsider advice and review treatment plans for further risk mitigations when BSARC declines an onward referral, embedding this practice and communicating it to practitioners.
Verbatim wording from the response “Following receipt of your concern, it has been agreed that where the Barnsley IHBT are informed that an onward referral has been declined by Barnsley Sexual Abuse and Rape Crisis Service (BSARC), the service will reconsider the suitability of the advice they have given to service users and families and review any proposed treatment plans to consider whether further risk mitigations or interventions are required to support the service user. This requirement will be embedded into team practice and communicated to all practitioners through team meetings and email communication.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Barnsley IHBT practitioners with access to comprehensive, up-to-date information about local mental health support services.
Verbatim wording from the response “Practitioners in the Barnsley Intensive Home-Based Treatment Team (IHBT) have access to a resource pack with comprehensive and up to date information regarding local mental health support services for people in psychological distress, which may not require a secondary care mental health response.” Source location Response from South West Yorkshire Partnership NHS Foundation Trust
Open published response
Concerns raised 1 Failure of mental health services to directly assess mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Ravensdale · 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
Mark Ravensdale had longstanding mental health difficulties and was found hanged, with the inquest concluding that he died by suicide. Mental health services discharged him without speaking to him directly or adequately assessing his mental health.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South West Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health services to directly assess mental health conditions
Wider context from the report “There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition.
” 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 Review the Single Point of Access triage process in response to the identified concern.
Verbatim wording from the response “Following receipt of the Regulation 28 report the Trust undertook a review of the SPA triage process specific to your concern, led by the Associate Director of Operations, Adults and Older People Mental Health Care Group.” Source location Response from South West Yorkshire Partnership 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 Develop and implement a triage checklist, using Plan-Do-Study-Act cycles, to identify when direct contact may be clinically indicated.
Verbatim wording from the response “It was identified that, although the outcome of any triage process is reached based upon an evidence-based approach in line with the UK Mental Health Triage (MHT) Scale Guidelines and a practitioner’s own clinical assessment, further guidance would support a practitioner to identify when direct contact with the person referred may be clinically indicated. The Trust will therefore develop and implement a triage checklist in respect of the review’s findings.” Source location Response from South West Yorkshire Partnership 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 Undertake an initial study of the triage checklist’s impact on service and care delivery after six months of implementation.
Verbatim wording from the response “An initial study of the triage checklist impact upon service and care delivery will be undertaken following 6 months of the checklist’s implementation, with appropriate actions taken as identified by the study.” Source location Response from South West Yorkshire Partnership NHS Trust
Open published response
Concerns raised 5 Failure to understand and apply risk-based information sharing View source Superficiality of suicide risk assessments View source Lack of a key worker approach View source Superficiality of communication with the family View source Failure to meaningfully communicate and engage with the armed forces View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Daniel Lee · 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
Daniel Lee, aged 22, died by hanging at a disused quarry on 16 September 2021, with the intention to end his life; the inquest concluded that his death was suicide. The report identified concerns about superficial risk assessments, the absence of a key worker, communication with the armed forces and family, and uncertainty about risk-based information sharing.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and apply risk-based information sharing
Wider context from the report “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust.
5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’.
5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it.
5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns.
5.5 There was evidence that staff in the team struggled with decision making around information sharing . For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information . In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing .
5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths:
• Superficiality of risk assessments
• Lack of a key worker approach
• Lack of communication with the armed forces, army in this case
• Superficiality of communication with the family
• Anxiety about appropriate risk sharing
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Superficiality of suicide risk assessments
Wider context from the report “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust.
5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention . The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’ .
5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it.
5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns.
5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing.
5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths:
• Superficiality of risk assessments
• Lack of a key worker approach
• Lack of communication with the armed forces, army in this case
• Superficiality of communication with the family
• Anxiety about appropriate risk sharing
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a key worker approach
Wider context from the report “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role . The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust.
5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’.
5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it.
5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns.
5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing.
5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths:
• Superficiality of risk assessments
• Lack of a key worker approach
• Lack of communication with the armed forces, army in this case
• Superficiality of communication with the family
• Anxiety about appropriate risk sharing
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Superficiality of communication with the family
Wider context from the report “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust.
5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’.
5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it.
5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing . This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests . The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns.
5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing.
5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths:
• Superficiality of risk assessments
• Lack of a key worker approach
• Lack of communication with the armed forces, army in this case
• Superficiality of communication with the family
• Anxiety about appropriate risk sharing
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully communicate and engage with the armed forces
Wider context from the report “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust.
5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’.
5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it .
5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns.
5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing.
5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths:
• Superficiality of risk assessments
• Lack of a key worker approach
• Lack of communication with the armed forces, army in this case
• Superficiality of communication with the family
• Anxiety about appropriate risk sharing
” Open source report
13 Jul 2022 Daniel Clements · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to provide coordinated continuing support for people with suicidal feelings without overt psychiatric illness View source Lack of a safe-care pathway for people displaying suicidal ideation without deemed mental illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Clements · 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
Daniel Clements, aged 27, was taken to hospital by police for a psychiatric assessment on 19 July 2021 and was discharged to his GP after being deemed not to have a mental illness. Later that evening, he ran into the path of a fast-moving train and sustained fatal injuries. The principal concerns were how to keep people displaying suicidal ideation safe when they are not considered mentally ill, and whether agencies adequately supported Mr Clements, who was described as vulnerable and had experienced homelessness and difficulties accessing support and medication.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coordinated continuing support for people with suicidal feelings without overt psychiatric illness
Wider context from the report “(4) Mr Clements was passed between agencies without any lasting benefit . This tragic situation illustrates the void in relation to those with suicidal feelings without any overt psychiatric illness .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe-care pathway for people displaying suicidal ideation without deemed mental illness
Wider context from the report “(1) How can a person displaying suicidal ideation be kept safe, if deemed not to be mentally ill?
” 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 Meet quarterly with partner organisations to resolve service-interface issues, maintain care pathways and update systems for service changes.
Verbatim wording from the response “The Trust’s services meet with partner organisations referred to above on a quarterly basis, the purpose of which is to resolve service interface issues, ensure smooth care pathways and the updating of the system to reflect any service changes. In addition to these meetings, the Trust will propose a meeting with its social care partner, Wakefield Local Authority, to raise with them the contents of your report.” Source location Response from South West Yorkshire Partnership
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 Social problems beyond secondary mental health services’ scope cannot be resolved by the Trust, which instead supports access to appropriate partner services.
Verbatim wording from the response “Where an intervention capable of reducing the risk of suicide can be provided by the Trust, we aim to achieve excellence in this regard, for example in the treatment of mood disorders. However, where resolution of a problem lies beyond the scope of services provided by the Trust, we endeavour to ensure that the person and their carers are offered support in accessing an appropriate service, often involving partner organisations.” Source location Response from South West Yorkshire Partnership
Open published response
Concerns raised 4 Failure to adhere to the hospital discharge protocol for self-discharge View source Failure to notify the intensive home-based treatment team of a patient's self-discharge View source Failure to assess and provide treatment by the in-house psychiatric team View source Delays in seeking updates from the hospital about a patient 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
Denton Donovan DUHANEY · 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
Denton Donovan Duhaney was admitted to hospital with physical and mental health concerns and was assessed as being at high risk of further mental health deterioration. He self-discharged without assessment by the hospital’s in-house psychiatric team or notification to the community treatment team, and was found dead at home several days later; the recorded cause of death was hanging (asphyxia), with a conclusion of suicide. The substantive concerns included failures in psychiatric assessment, discharge protocol, communication about the self-discharge, and follow-up arrangements.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the hospital discharge protocol for self-discharge
Wider context from the report “2. Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr Duhaney expressed a wish to self-discharge.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the intensive home-based treatment team of a patient's self-discharge
Wider context from the report “3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and provide treatment by the in-house psychiatric team
Wider context from the report “1. Mr Duhaney was a patient at Pinderfield’s Hospital between 23rd and 25th June but at no time was he assessed or receive treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking updates from the hospital about a patient
Wider context from the report “4. Kirklees Home Based Treatment Team last had contact with Pinderfield’s Hospital on 24th June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr Duhaney.
” 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 Disseminate guidance requiring community services to maintain contact with service users awaiting acute-hospital discharge and coordinate with liaison teams or acute wards.
Verbatim wording from the response “I will today be producing and disseminating guidance to staff within the Trust community services (not just the Intensive Home Based Treatment Team) to provide clear instructions around maintaining contact with a service user awaiting discharge from an acute hospital, but equally to maintain contact with the Psychiatric Liaison Team and/or Acute Ward to ensure a seamless transition of care into the community.” Source location 2021-0200-Response-from-Fieldhead-Hospital_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend Psychiatric Liaison Team standard operating procedures to ensure consistent Trust-wide practice.
Verbatim wording from the response “The Standard Operational Policy for the two teams [Wakefield/Dewsbury and Calderdale/Kirklees Psychiatric Liaison Team] has been reviewed and amended to ensure consistency of practice across the Trust’s Psychiatric Liaison Teams (e.g. there is no difference in the processes of the Wakefield/Dewsbury PLT, and the Calderdale/HRI PLT as a result).” Source location 2021-0200-Response-from-Fieldhead-Hospital_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain patients assessed by a Psychiatric Liaison Team on its caseload until they leave the hospital site, enabling further review if risk changes.
Verbatim wording from the response “I can confirm that any patients assessed by a Psychiatric Liaison Team in a hospital setting remain on the team’s caseload until the patient leaves the hospital site. Therefore, if the patients risk change prior to them leaving the hospital the team will be able to provide a review of the patient and offer support as needed.” Source location 2021-0200-Response-from-Fieldhead-Hospital_Published
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 a more detailed review of contact arrangements for service users awaiting discharge from acute hospitals.
Verbatim wording from the response “The above is intended to be an interim measure and going forward a more detailed review of this issue will be undertaken.” Source location 2021-0200-Response-from-Fieldhead-Hospital_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge protocol was implemented by Mid Yorkshire Hospitals NHS Trust, so this respondent will not respond to that concern.
Verbatim wording from the response “The above relates to the discharge protocol implemented by Mid Yorkshire Hospitals NHS Trust. We do not propose responding to this concern.” Source location 2021-0200-Response-from-Fieldhead-Hospital_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mid Yorkshire Hospitals NHS Trust will provide its own response regarding the hospital’s notification of the community team after self-discharge.
Verbatim wording from the response “Points 3 and 4 above have elements that overlap, and we have therefore responded to both below. It is understood that Mid Yorkshire Hospitals NHS Trust will also provide their own response to point 3 as this can be interpreted to apply to both Trusts.” Source location 2021-0200-Response-from-Fieldhead-Hospital_Published
Open published response
Concerns raised 21 Lack of procedures for safeguarding care data View source Lack of procedures for care handovers View source Failure to implement procedures for displaying SALT and allergy advice in service users’ kitchens View source Failure to incorporate significant relevant factors into regulatory risk assessment View source Failure to provide updated care information to visiting professionals View source Delays in CQC access to police and provider records after a significant event View source Inadequate safeguarding of service-user information on staff personal mobile phones View source Over-reliance on WhatsApp for care-plan updates causing delays in updating home support plans View source Unclear SALT guidance on consistency descriptions and modified or avoided foods View source Failure to promptly share policy and legislative changes through the organisation’s website View source Lack of contingency planning for sickness of the Director View source Lack of consistency in CQC decisions on using evidence for inspections or regulatory action View source Lack of procedures governing completion, storage, updating and review of risk assessments and care plans View source Lack of procedures for auditing care documentation and practice View source Failure to assign lead-carer responsibility for accurate and current home documentation View source Failure to maintain correct care plans and risk assessments at service users’ home addresses View source Failure to communicate care-plan updates to all caring staff View source Lack of understanding of the Mental Capacity Act in care delivery View source Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan View source Lack of a transparent and candid organisational culture View source Inaccurate and misleading regulatory inspection reporting View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Wilkinson · 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
Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for safeguarding care data
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded ; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for care handovers
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken . This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement procedures for displaying SALT and allergy advice in service users’ kitchens
Wider context from the report “(7) There was no evidence that fundamental matters such as standard operating procedures for displaying SALT advice or allergy advice in a service users’ kitchen where all can see it have been implemented by the Stars Social Support Limited.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate significant relevant factors into regulatory risk assessment
Wider context from the report “(15)CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide updated care information to visiting professionals
Wider context from the report “(6) Secondly, visiting professionals are not able to access the WhatsApp group and therefore will not be in receipt of this updated information which may be important for some service users.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in CQC access to police and provider records after a significant event
Wider context from the report “(13)CQC did not take adequate steps to access records held by the Police or the provider in a timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate safeguarding of service-user information on staff personal mobile phones
Wider context from the report “(4) Stars Social Support Limited have implemented the use of WhatsApp to ensure staff are aware of updates to service users plans and they require staff to confirm they have read and understood the update prior to caring for an individual. Whilst this is a positive use of technology to support staff in caring for service users it is in itself a safeguarding issue to hold personal information about the service user on personal mobile phones ; this is especially the case where there are not adequate policies in place around the use of personal phones by staff members .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on WhatsApp for care-plan updates causing delays in updating home support plans
Wider context from the report “(5) The use of the WhatsApp group adds in two risks of its own, the first is that there is an over reliance on this being the means by which service users care plans are updated and by default this ends up being the service users care plan. This makes it more likely rather than less likely in my view that support plans in the service users’ home will not be updated in a timely fashion .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear SALT guidance on consistency descriptions and modified or avoided foods
Wider context from the report “(18)The advice from SALT was not an issue in this case, it was the application of this advice which was the primary concern. I would like to commend the approach that the Trust have taken in learning from the issues which I raised at the conclusion of the proceedings and the openness with which the Trust have received the concerns I had. The guidance sheets which have been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided . This needs to be reviewed to avoid confusion.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly share policy and legislative changes through the organisation’s website
Wider context from the report “(2) Stars Social Support Limited do not utilise their own website to ensure that policy and legislative changes can be adequately and promptly shared with service users, their families, and staff.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of contingency planning for sickness of the Director
Wider context from the report “(9) There is now a significant reliance on the Director updating all records and delivering care and undertaking audits whilst she improves the culture of the organisation. There was no adequate description of contingency plans in the event of sickness of this individual .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistency in CQC decisions on using evidence for inspections or regulatory action
Wider context from the report “(17)Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory action, they ought to ensure there is a consistent approach to this including the consideration of policies and standard operating procedures . This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of Regulation may be compromised.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures governing completion, storage, updating and review of risk assessments and care plans
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented ; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for auditing care documentation and practice
Wider context from the report “(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken ; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign lead-carer responsibility for accurate and current home documentation
Wider context from the report “(10)The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain correct care plans and risk assessments at service users’ home addresses
Wider context from the report “(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate care-plan updates to all caring staff
Wider context from the report “(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the Mental Capacity Act in care delivery
Wider context from the report “(8) There remained a lack of understanding about the mental capacity act and how that may affect the care delivery to service users where it meant that a carer or senior manager had to be the decision maker for specific aspects of their care such as nutrition or medication
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate regulatory risk in response to provider non-engagement and lack of an action plan
Wider context from the report “(14)CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a transparent and candid organisational culture
Wider context from the report “(1) Stars Social Support Limited have a culture which does not encourage transparency or embrace the duty of candour . This was evidenced throughout the inquest proceedings and in the lack of engagement with CQC during the inspection regime.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and misleading regulatory inspection reporting
Wider context from the report “(16)The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to this service where that ought not to be the case. The report published in October 2020 refers to their being no evidence of harm however there is a woeful lack of detail about the context of this within the report .
” 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 Revise and implement level 6 food consistency advice sheets by removing misleading images, clarifying wording, and separating avoidable foods from modifiable options.
Verbatim wording from the response “On 18th May 2021, ████████ along with other Learning Disability Speech and Language Therapists, met and reviewed the services level 6 food consistency advice sheets in their Dysphagia Speech and Language Therapy Learning Disability meeting. As a result of this review, the advice sheets were amended in response to your concerns as follows:” Source location 2021-0102-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
Concerns raised 2 Lack of psychologist input on the ward View source Failure to ensure clinical management and leave decisions are made by responsible clinical staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Kate DORMAN · 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
Emma Kate DORMAN died by asphyxiation by hanging on 24 February 2020 after being allowed leave from the Priestley Unit, Dewsbury & District Hospital. The leave was changed at short notice because of bed availability, and the planned visit by the Home Based Treatment Team did not take place. Concerns included non-clinical influence over the leave decision and the lack of psychologist input on the ward for more than three years.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of psychologist input on the ward
Wider context from the report “2. That there was no psychologist input on the ward , which had persisted for over three years prior to this incident . The only steps taken to alleviate this vacancy was to re-advertise the same post with the same level of remuneration .
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinical management and leave decisions are made by responsible clinical staff
Wider context from the report “1. That the decision of leave was dominated by the non-clinical team through the Bed Manager and clinical staff felt they could not object . The draft amended clarification still enable those not directly responsible for patient care to effect clinical management of the patient .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor inpatient staff understanding of patient-flow procedures and responsibilities through the Matrons’ monthly checklist.
Verbatim wording from the response “I can confirm that inpatient staff understanding of the procedure, and the responsibilities of those involved in the patient flow process (including that of ward staff and of patient flow staff) will be monitored through the Matron’s monthly checklist.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use redesigned, flexible-working and job-sharing approaches to attract applicants for Clinical Psychologist posts.
Verbatim wording from the response “The Trust has taken various approaches to attract applicants to such posts, including redesign, flexible working and job sharing, but sadly the national shortage from Clinical Psychologists continues to impact on the Trust’s ability to appoint to these posts.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
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 Provide inpatient staff with the Patient Flow Procedure and information clarifying patient-flow roles and responsibilities.
Verbatim wording from the response “In light of the above and your concerns, the Trust have provided all staff within the Inpatient setting a copy of the current Patient Flow Procedure, accompanied with information specifically detailing theirs and their colleague’s roles as part of the patient flow process.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
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 Provide interim in-reach psychology support to Ward 18 through a Clinical Psychologist from the CORE community team.
Verbatim wording from the response “In the interim and until we have recruited to the above psychology post a Clinical Psychologist working within the CORE community team will provide in-reach psychology support to Ward 18.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate the Ward 18 part-time Psychologist post into Psychology services based within Community Services.
Verbatim wording from the response “As per ████████ addendum statement dated 12th February 2021, subsequent to the six failed attempts to recruit a part time Psychologist to Ward 18, an agreement was made for the Ward 18 part time Psychologist post to be incorporated into the Psychology services that are based within Community Services.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the skill mix of existing vacant psychology posts to support consideration of a funding-related banding increase.
Verbatim wording from the response “The Community Services are currently reviewing the skill-mix for existing vacant psychology posts in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological Therapy Lead will review and update the Job Description and Person Specification for the role. Once the updated Job Description and Person Specification has been drafted, it will be submitted to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be advertised. We anticipate this process will conclude in June 2021.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the psychology role’s Job Description and Person Specification after the skill-mix review.
Verbatim wording from the response “The Community Services are currently reviewing the skill-mix for existing vacant psychology posts in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological Therapy Lead will review and update the Job Description and Person Specification for the role. Once the updated Job Description and Person Specification has been drafted, it will be submitted to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be advertised. We anticipate this process will conclude in June 2021.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
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 Submit the updated psychology role documentation to the Agenda for Change banding review panel.
Verbatim wording from the response “The Community Services are currently reviewing the skill-mix for existing vacant psychology posts in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological Therapy Lead will review and update the Job Description and Person Specification for the role. Once the updated Job Description and Person Specification has been drafted, it will be submitted to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be advertised. We anticipate this process will conclude in June 2021.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
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 Employ several Matrons with clinical and operational responsibility for inpatient wards.
Verbatim wording from the response “The Trust notes your continued concern over the decision making by Registered Clinical Staff (Bed Flow Managers) who are not always involved at ward level. Over the past 2 years the Trust has undertaken an extensive review of its clinical structures and has employed several Matrons within its Inpatient settings. The Matrons are clinically and operationally responsible for each Ward” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National shortages of Clinical Psychologists constrain the Trust’s ability to appoint to the vacant Ward 18 psychology post.
Verbatim wording from the response “Unfortunately, the Trust has had a high vacancy rate for Clinical Psychologist posts over the last couple of years as a result of the national shortages surrounding the profession.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical patient-flow procedures, ward oversight and escalation arrangements are considered sufficient to support clinically led admission decisions.
Verbatim wording from the response “The Trust has a Patient Flow Procedure that provides a framework for staff relating to activities around pre-admission, bed allocation and management processes, the inpatient stay and discharge of service users. The procedure is used to support decisions and management of service users from the point when they require access to an inpatient bed, through to their discharge from a ward. The Patient Flow (Bed Management) Team are involved in the application of the patient flow process across the Trust by working in partnership with the Inpatient services. The Patient Flow Team is a clinically led service.” Source location 2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Open published response
14 Dec 2018 BARNABY LUKE AYLWARD · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 8 Failure to share relevant risk information between agencies View source Failure to conduct regular multi-agency preventative review and reassessment of fire risks View source Failure to carry out regular property inspections and provide assistance View source Failure to record significant clutter and associated risk in clinical notes View source Lack of collective or assigned responsibility for reducing home fire risk View source Limited efforts to extend practical and financial support through family members View source Failure of care plan documentation to record behavioural fire risks and planned review View source Failure to facilitate private professional discussion during risk management and MHA assessment View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BARNABY LUKE AYLWARD · 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
Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant risk information between agencies
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies .
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct regular multi-agency preventative review and reassessment of fire risks
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time ;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out regular property inspections and provide assistance
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist ;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant clutter and associated risk in clinical notes
Wider context from the report “(3) The presence of clutter and thus risk was not always evidenced in other clinical notes as a symptom of Mr Aylward's illness of significance as were other presentations of his illness.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of collective or assigned responsibility for reducing home fire risk
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed ;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited efforts to extend practical and financial support through family members
Wider context from the report “(4) There was some but not much evidence of seeking to extend support to Mr Aylward through his family members including practical and financial help.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of care plan documentation to record behavioural fire risks and planned review
Wider context from the report “(2) The mental health care delivered to Mr Aylward was within a Care Planning Approach. The Care Plan documentation did not identify his above behaviours in writing and thus potential risks, nor indicate review and solutions including with housing provision
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate private professional discussion during risk management and MHA assessment
Wider context from the report “(5) The appropriateness for a risk management meeting and also MHA assessment in part to be held away from the patient to enable frank discussions to take place between mental health professionals rather than in front of the patient perhaps more robust views may not have been enabled .
” 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 Reinforce inclusion of family and carers in care planning and risk management through training, the information leaflet and staff alert.
Verbatim wording from the response “Learning events have previously been provided by the safeguarding team which includes raising awareness to include carers and family in care planning and risk management, this will continue to be reinforced through our mandatory and core clinical training programmes. This will be reinforced through the publication of the above mentioned information leaflet and alert.” Source location 2018-0387-Responses
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 Reinforce consent-based information sharing with housing providers and referrals to fire services when fire risks are identified.
Verbatim wording from the response “Staff will be reminded through the safeguarding training and information governance training that where a service user is in rented accommodation, consent should be sought from the service user to provide information regarding the condition of the property to the housing provider.” Source location 2018-0387-Responses
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 Distribute a staff alert requiring hoarding-related risks and planned interventions to be recorded in care plans.
Verbatim wording from the response “An alert will be distributed to all staff working in the Trust raising awareness that where there is a risk relating to hoarding and associated risks this should be included within the care plan and that interventions should be planned to manage the risk. These should be reviewed on a regular basis or as the risk changes. The alert will be distributed by the end of February 2019.” Source location 2018-0387-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and agree the inter-agency information-sharing protocol with West Yorkshire Fire and Rescue Service.
Verbatim wording from the response “The Trust currently has an inter-agency information sharing protocol with West Yorkshire Fire and Rescue service, this protocol is currently under review and it is anticipated that this should be agreed by the end of March 2019.” Source location 2018-0387-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Management of people facing multiple risks is not solely the Trust’s responsibility and requires housing, fire and rescue, family, and carer involvement.
Verbatim wording from the response “The Trust has in place guidance in various forms to assist staff in supporting service users who may be vulnerable. There are a number of partnership arrangements where both health and local authority work together to provide care and treatment to people in the community. It is important that staff from all agencies recognise that the management of a person who may be at risk for a number of reasons is not the sole responsibility of one agency. Going forward Trust staff should be encouraged to use the knowledge and expertise of other agencies such as housing and fire and rescue services. The knowledge of family and carers is also a very important element when caring for vulnerable people.” Source location 2018-0387-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MHA assessments may limit professionals’ opportunities for private discussion because time, space and urgent safety requirements constrain the process.
Verbatim wording from the response “The role of the AMHP and the medical staff within the MHA assessment process is to act as an independent assessor but additionally as part of that role it is their responsibility to ensure they have collected available information and views of all involved in the person’s care. Often MHA assessments are at the point of crisis for a service user and as such opportunities for discussion are limited by time, space and urgency to preserve safety, but where possible efforts should be made for the professionals involved to have a conversation not in the presence of the service user in order to establish a plan of care.” Source location 2018-0387-Responses
Open published response
23 May 2018 Grahame Searby · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1 Lack of mental health team access to appropriate GP data via EMIS 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
Grahame Searby · 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
Grahame Searby, who had extreme anxiety and depression and was under community mental health supervision, was found hanging at his home on 27 July 2017. The principal concern was that the mental health team lacked access to the GP database through EMIS, limiting information gathering about his care.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health team access to appropriate GP data via EMIS
Wider context from the report “During the evidence ████████ and ████████ informed me that at the time of Mr Searby’s death, the mental health team did not have access to the system one database or EMIS for the purposes of referencing the GP’s database. Although I was told that access via the system one data base is currently in operation, there is still no access to the appropriate date via EMIS
” Open source report
3 May 2017 Margaret Elizabeth Conway · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Difficulties in transferring patients with serious mental and physical health problems View source Geographical and operational separation of Acute Medical Wards Mental Health Services 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
Margaret Elizabeth Conway · 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
Margaret Elizabeth Conway, aged 68, was admitted to Pinderfields Hospital with diarrhoea, acute kidney injury and pancolitis after being transferred from Fieldhead Hospital. She suffered a cardiac arrest and died at 0110 hours on 3 September 2016; the inquest recorded natural causes, including acute myocardial infarction and acute severe colitis. The substantive concerns related to the challenges of transferring and caring for patients with both serious mental and physical health problems across geographically and operationally separate services.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in transferring patients with serious mental and physical health problems
Wider context from the report “With the assistance of Professor Stephen Curran, Consultant in Old Age Psychiatry and Clinical Lead who is based at Fieldhead Hospital and who was involved in Mrs Conway’s care, I wish to address the issue of patients experience in mental health issues and who are in-patients at Fieldhead Hospital but who have or developed physical health problems acutely which require treatment.
(1) The Acute Medical Wards Mental Health Services are geographically and operationally separate.
(2) Transfers of patients who are experiencing both serious mental and physical health problems can sometimes be very challenging.
(3) PLT Services are now more actively involved in patients transferring to the Acute Wards.
(4) Closer working such as joint ward rounds and NDT working should be explored as well as the development of a clear pathway/flowchart to facilitate closer working and in the longer-term the development and use of a shared resource with a small number of jointly funded and managed beds. Such measures would improve the care of patients with both severe physical and mental illness and also reduce the need for multiple transfers between the two organisations.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Geographical and operational separation of Acute Medical Wards Mental Health Services
Wider context from the report “With the assistance of Professor Stephen Curran, Consultant in Old Age Psychiatry and Clinical Lead who is based at Fieldhead Hospital and who was involved in Mrs Conway’s care, I wish to address the issue of patients experience in mental health issues and who are in-patients at Fieldhead Hospital but who have or developed physical health problems acutely which require treatment.
(1) The Acute Medical Wards Mental Health Services are geographically and operationally separate.
(2) Transfers of patients who are experiencing both serious mental and physical health problems can sometimes be very challenging.
(3) PLT Services are now more actively involved in patients transferring to the Acute Wards.
(4) Closer working such as joint ward rounds and NDT working should be explored as well as the development of a clear pathway/flowchart to facilitate closer working and in the longer-term the development and use of a shared resource with a small number of jointly funded and managed beds. Such measures would improve the care of patients with both severe physical and mental illness and also reduce the need for multiple transfers between the two organisations.
” Open source report
12 Dec 2013 Jane Dyson Gabbitas · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of arrangements to record and monitor resident absences View source Failure to react appropriately to inappropriate or particularly lengthy resident absences View source
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jane Dyson Gabbitas · 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
Jane Dyson Gabbitas was found unconscious in an abandoned car on 2 March 2013 and died at the scene despite resuscitation attempts. The inquest concluded that she died after ingesting sufficient quantities of alcohol and gabapentin to cause her death. The report raised concerns about the failure to record and monitor her absence from the SHARE accommodation unit and to respond appropriately to lengthy or inappropriate absences.
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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements to record and monitor resident absences
Wider context from the report “The inquest revealed a period of time on the day of her death from approximately 1.40pm to 6pm when Mrs Gabbitas was absent from SHARE, and she never returned, her body then having been discovered some distance away. Staff at SHARE were aware that she had indicated an intention to go out, but apparently were not aware of the full extent of her absence until telephoned by Mrs Gabbitas’ daughter to say her mother’s body had been found by police. It was not clear if there was any sign-in /out arrangement or any reception facility at SHARE to account for absences.
I consider that, although I did not find that Mrs Gabbitas’ death would have been prevented by earlier attention to her absence, there is a risk that future deaths may occur in similar circumstances if no action is taken to record and monitor absence , albeit informally (in keeping with the nature of the care in the SHARE unit), and to react appropriately to absences which appear to be inappropriate or particularly lengthy.
” 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 Yorkshire Partnership Teaching NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to react appropriately to inappropriate or particularly lengthy resident absences
Wider context from the report “The inquest revealed a period of time on the day of her death from approximately 1.40pm to 6pm when Mrs Gabbitas was absent from SHARE, and she never returned, her body then having been discovered some distance away. Staff at SHARE were aware that she had indicated an intention to go out, but apparently were not aware of the full extent of her absence until telephoned by Mrs Gabbitas’ daughter to say her mother’s body had been found by police. It was not clear if there was any sign-in /out arrangement or any reception facility at SHARE to account for absences.
I consider that, although I did not find that Mrs Gabbitas’ death would have been prevented by earlier attention to her absence, there is a risk that future deaths may occur in similar circumstances if no action is taken to record and monitor absence, albeit informally (in keeping with the nature of the care in the SHARE unit), and to react appropriately to absences which appear to be inappropriate or particularly lengthy.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations