Recipient

Spider Project Café71

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First report 2 May 2024•Latest report 2 May 2024

Recipient record

Reports, concerns and published responses

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
1

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

100%published responses found
1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Spider Project Café71 linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cheshire

    AI-generated summary

    Evie Jane DAVIES · 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

    Evie Jane Davies was found deceased at home on 2 December 2021 after taking a significant overdose of medication that had not been prescribed to her. The report states that this was likely a deliberate act intended to end her life, amid deteriorating mental health and significant personal stressors. The principal concern was insufficient real-time information sharing between the café71 crisis service, the mental health team and the GP, potentially preventing prompt follow-up of people at risk.

    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 Spider Project Café71; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors

    Wider context from the report

    “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner. ”
    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 Spider Project Café71; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to notify the mental health team when a person has contacted the café71 service

    Wider context from the report

    “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner. ”
    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 Spider Project Café71; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in GP review of correspondence relevant to mental health team action

    Wider context from the report

    “The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner. ”
    Open source report

    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 NHS Crisis Line, which received the call, was responsible for notifying the mental health team.

    Verbatim wording from the response

    “Also in point 5, there is a sentence regarding a lack of notification to the mental health team about EJD being in contact, but again, this would be the Crisis Line who would notify the mental health team as it was them who received the phone call.”

    Source location

    Response from Spider Project
    Page 2 · response
    Published 14 May 2024

    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

    Cafe 71 disputes that EJD contacted it, that it was a crisis line, or that referral information indicated immediate risk.

    Verbatim wording from the response

    “In point 4 of the report it says that EJD called the Crisis Line and was directed to Cafe 71. We want to make it clear that EJD did not ever call Cafe 71, the only call that we are aware of was to the NHS Crisis Line.”

    Source location

    Response from Spider Project
    Page 2 · response
    Published 14 May 2024

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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

Data last updated 7 September 2026