9 Mar 2020 Rebecca Jane Hursey · Prevention of Future Deaths report Inner West London
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Concerns raised 7 Failure to share complex and high-risk patients between units early in the inpatient stay View source Failure to consider bespoke placements early for complex patients View source Failure to verbally communicate increased suicidal risk to the responsible nurse View source Failure to prioritise timely safer placements for patients at high risk of self-harm View source Failure to base staff handovers on clinical-record examination and update care plans for risk management View source Lack of deadlines for finding alternative placements View source Risk of clinical silos between sections of mental health services View source See 4 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations