Recipient

Springfield University Hospital

First report 9 Mar 2020•Latest report 9 Mar 2020

Recipient record

Reports, concerns and published responses

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

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

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Springfield University Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

9 Mar2020
Inner West London
Concerns raised7
1. Failure to share complex and high-risk patients between units early in the inpatient stay
2. Failure to consider bespoke placements early for complex patients
3. Failure to verbally communicate increased suicidal risk to the responsible nurse
1. Failure to prioritise timely safer placements for patients at high risk of self-harm
2. Failure to base staff handovers on clinical-record examination and update care plans for risk management
3. Lack of deadlines for finding alternative placements
4. Risk of clinical silos between sections of mental health services
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

Rebecca Jane Hursey · 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

Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.

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 Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to share complex and high-risk patients between units early in the inpatient stay
Wider context from the report
“6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service 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 Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider bespoke placements early for complex patients
Wider context from the report
“5. That bespoke placements are considered early in the discharge process for complex patients. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to verbally communicate increased suicidal risk to the responsible nurse
Wider context from the report
“2. That practitioners who recognise increase in suicidal risk of a patient should pass this on verbally to the nurse on charge of the ward or the nurse allocated to the patient. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to prioritise timely safer placements for patients at high risk of self-harm
Wider context from the report
“4. That placements for patients with high risk of self-harm, such as Rebecca are prioritised such that safer placements are found within 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 Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to base staff handovers on clinical-record examination and update care plans for risk management
Wider context from the report
“1. That staff handovers be led by examination of the clinical record such that recent progress can be assessed especially in relation to risk management and care plans amended accordingly. ”
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 Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of deadlines for finding alternative placements
Wider context from the report
“3. That NHS England consider a system of introducing deadlines for alternative placements to be found for such patients, so that they must be found 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 Springfield University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Risk of clinical silos between sections of mental health services
Wider context from the report
“6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Failure to share complex and high-risk patients between units early in the inpatient stay

Failure to consider bespoke placements early for complex patients

Failure to verbally communicate increased suicidal risk to the responsible nurse

Failure to prioritise timely safer placements for patients at high risk of self-harm

Failure to base staff handovers on clinical-record examination and update care plans for risk management

Lack of deadlines for finding alternative placements

Risk of clinical silos between sections of mental health services