4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 more concerns
Responses linked to these concerns
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AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained mental health nurses for acute psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them . This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients .
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team .
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for 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 Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.
Verbatim wording from the response “The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.” Source location Response from NHS Surrey and Borders 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 Increase the number of funded inpatient mental health beds for the Trust’s population.
Verbatim wording from the response “The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.” Source location Response from NHS Surrey and Borders 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 Continue collaborative work with SECAMB and system partners to support timely and safe joint decision making, including regular operational meetings.
Verbatim wording from the response “We are aware that South East Coast Ambulance Service (SECAMB) has recently approved a written protocol relating to mental capacity and suicidality which provides that the HCPL should be consulted when safety planning for patients in Surrey. The Trust has seen an overall increase in the number of calls from ambulance staff in recent months, from 52 calls in April 2025 to 105 in August 2025. A weekly operational meeting is held between the two trusts to discuss processes and resolve any issues that may arise.” Source location Response from NHS Surrey and Borders 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 Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Verbatim wording from the response “Further improvement work continues through the Mind and Body Provider Collaborative, which is a programme of work chaired by our Chief Nursing Officer and undertaken with our acute care partners.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
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 Healthcare Professionals Line is considered sufficient for safe, situation-specific multi-agency decisions instead of relying on previously prepared joint plans.
Verbatim wording from the response “The use of the Healthcare Professionals Line (HCPL) is crucial in ensuring appropriate and safe multi agency decision making. A joint plan, prepared at an earlier juncture, cannot be relied upon to enable the ambulance service, or other professionals, to make decisions in emergency or crisis situations.” Source location Response from NHS Surrey and Borders 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 The acute hospital’s management is responsible for deciding whether to detain a patient to an acute hospital bed.
Verbatim wording from the response “A person can only be detained once admitted to an acute hospital bed. While the Trust’s position is that steps should be taken to ensure an appropriate legal framework, the decision to detain to an acute hospital bed lies with the management of the acute hospital. This is not an issue unique to Surrey; one of the proposed amendments to the Mental Health Bill is to allow people to be detained in emergency departments in recognition of the current gap in legislation.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Open published response
15 Jan 2025 Tammy Denise Milward · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Insufficient coordination and communication between primary and secondary care providers View source Failure of primary and secondary care providers to access each other’s electronic medical records 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
Tammy Denise Milward · 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
Tammy Denise Milward, who had severe obsessive compulsive disorder and dependence on prescribed medication, was found unresponsive at home on 1 January 2024 after concerns were raised about her wellbeing. The medical cause of death was mixed drug toxicity, with toxicology showing prescribed medication in excess of prescribed levels and cocaine use shortly before her death. The principal concern was limited coordination and communication between primary and secondary care providers, including poor connectivity between their electronic record systems.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient coordination and communication between primary and secondary care providers
Wider context from the report “The Inquest heard evidence that Ms Milward’s case presented treatment challenges which several agencies sought to address but there was limited coordination, in particular that:
a. The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS. As a result, neither the GP practice, nor GPimhs was aware that the other had received messages from or about Ms Milward on 28 December 2023. The coroner heard from SABP that there is ongoing work ongoing to create greater connectivity between the various electronic record systems, but this work is not yet complete.
b. The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs . The coroner was told that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support) but that levels of interaction varied and was sometimes also undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices.
The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of primary and secondary care providers to access each other’s electronic medical records
Wider context from the report “The Inquest heard evidence that Ms Milward’s case presented treatment challenges which several agencies sought to address but there was limited coordination, in particular that:
a. The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS . As a result, neither the GP practice, nor GPimhs was aware that the other had received messages from or about Ms Milward on 28 December 2023. The coroner heard from SABP that there is ongoing work ongoing to create greater connectivity between the various electronic record systems, but this work is not yet complete .
b. The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs. The coroner was told that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support) but that levels of interaction varied and was sometimes also undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices.
The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death.
” Open source report
14 Oct 2024 Locket Ure Williams · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Unavailability of fully operational in-county psychiatric in-patient beds for children View source Failure of CAMHS staff to attend or engage with Core Group Meetings View source Lack of a clear and obvious suicide-risk alert in children’s medical records View source Insufficient in-county psychiatric in-patient bed capacity for children View source Inability of in-county psychiatric in-patient provision to treat children with eating disorders or needing psychiatric intensive care View source Lack of monitoring and systematic recording of CAMHS staff participation in Core Group Meetings View source Failure of My Safety Plans to clearly convey suicide risk View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Locket Ure Williams · 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
Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of fully operational in-county psychiatric in-patient beds for children
Wider context from the report “Concern 1
The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all.
At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening , (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of CAMHS staff to attend or engage with Core Group Meetings
Wider context from the report “Concern 4
From the evidence I heard at the inquest hearing, it was apparent that staff within CAMHS did not always attend or engage with Core Group Meetings to which they were invited by children’s services .
At the prevention of future deaths hearing, it was accepted that, for those children under Children’s Services, active involvement in Core Group Meetings by all agencies involved with the child was of real importance. This was so, because the meetings were the means by which information was shared by different agencies and an informed plan was made to protect the child’s life (including from suicide) and welfare. Failure by Trust staff to attend or otherwise to engage with the meetings, and the other agencies involved with the child, may therefore raise the risk to the child and undermine their protection .
I was also told that there is an expectation that Trust staff should prioritise attendance / involvement in Core Group Meetings but, it seems, that no monitoring takes place to assess compliance with that expectation, including no systematic recording of the receipt of invitations to attend Core Group Meetings and no systematic recording of the response by the staff who have been invited, or otherwise.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear and obvious suicide-risk alert in children’s medical records
Wider context from the report “Concern 2
On the basis of the evidence I heard at the inquest hearing, I found that Locket’s death was contributed to by the Trust’s underestimation of their risk of suicide.
At the prevention of future deaths hearing, I was told that the Trust has introduced a new risk assessment system. The new system is in accordance with NICE guidelines and relies on a fuller description of the nature and level of the risk rather than its classification as low, medium, or high.
It is clear from the evidence that there is good reason to move away from the three-tier classification, but I am concerned that the new system does not include any clear and obvious alert, on the medical records, that there is a risk of suicide in relation to the child in question . Although the intention of the new system is to encourage each clinician to read the narrative of the fuller risk assessment, there is currently a risk that, if they do not do so (and it is foreseeable that they will not always do so or be able to do so), they will be unaware of the risk of suicide .
It was accepted in the evidence that an alert for a risk of suicide could be included in a child’s record without undermining the move away from the three-tier classification of that risk as low, medium or high.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient in-county psychiatric in-patient bed capacity for children
Wider context from the report “Concern 1
The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all.
At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time , and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability of in-county psychiatric in-patient provision to treat children with eating disorders or needing psychiatric intensive care
Wider context from the report “Concern 1
The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all.
At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring and systematic recording of CAMHS staff participation in Core Group Meetings
Wider context from the report “Concern 4
From the evidence I heard at the inquest hearing, it was apparent that staff within CAMHS did not always attend or engage with Core Group Meetings to which they were invited by children’s services.
At the prevention of future deaths hearing, it was accepted that, for those children under Children’s Services, active involvement in Core Group Meetings by all agencies involved with the child was of real importance. This was so, because the meetings were the means by which information was shared by different agencies and an informed plan was made to protect the child’s life (including from suicide) and welfare. Failure by Trust staff to attend or otherwise to engage with the meetings, and the other agencies involved with the child, may therefore raise the risk to the child and undermine their protection.
I was also told that there is an expectation that Trust staff should prioritise attendance / involvement in Core Group Meetings but, it seems, that no monitoring takes place to assess compliance with that expectation , including no systematic recording of the receipt of invitations to attend Core Group Meetings and no systematic recording of the response by the staff who have been invited , or otherwise.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of My Safety Plans to clearly convey suicide risk
Wider context from the report “Concern 3
I also heard that a child at risk of suicide may now be provided with a document, called “My Safety Plan”, one purpose of which is to help the child to communicate with others (including for example family members, teachers, and social workers) about their condition and risk. I was told that, if a child does not want to refer in the document to the risk of suicide, other terms such as “distress” may be used.
To the extent that part of the purpose of the My Safety Plan is to enable the child to communicate their risk of suicide and thereby receive help to stay safe, I am concerned that by substituting the word “distress” for “suicide”, some plans may not refer to suicide and may not therefore ensure that the nature of the risk is clearly conveyed to those from whom the child may seek support, and to the responsible adults in their life .
” 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 Request that Children’s Services copy Core Group meeting invitations to the Trust’s central Safeguarding team.
Verbatim wording from the response “The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.” Source location Response from Surrey and Borders Partnership NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade the importance of clinician engagement with Core Group meetings to community teams.
Verbatim wording from the response “Attendance at Core Group meetings in respect of those supported by Children’s Services is mandatory. There is also an expectation that clinicians contribute to other safeguarding meetings, and local authority reviews of Education Health and Care Plans (“EHCP”). The Standard Operating Procedure (“SOP”) for our community teams requires that Care Plans include actions flowing from these meetings. Care Plans are recorded on SystmOne and accessible to any Trust clinician involved in the care of the child or young person.” Source location Response from Surrey and Borders Partnership NHS
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 Open Emerald Place to provide additional general adolescent unit inpatient bed capacity in Surrey.
Verbatim wording from the response “Typically, 6-8 General Adolescent Unit inpatient beds are required at any given time within Surrey. Emerald Place was opened by the Trust in partnership with a private provider, Elysium Healthcare, in March 2024. Emerald Place has sufficient bed capacity to meet the demand for GAU inpatient beds within Surrey.” Source location Response from Surrey and Borders Partnership NHS
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 Formal risk documentation and information-sharing procedures are considered sufficient; My Safety Plan is not intended to record or share clinical suicide risk.
Verbatim wording from the response “My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it is not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.” Source location Response from Surrey and Borders Partnership NHS
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 Trust cannot monitor or arrange attendance for Core Group invitations it does not receive from Children’s Services in time.
Verbatim wording from the response “The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.” Source location Response from Surrey and Borders Partnership NHS
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 Trust considers its needs-based risk assessment and reduction process sufficient, so will not introduce a binary suicide-risk flag.
Verbatim wording from the response “It is recognised that risk prediction in suicide has been shown repeatedly to be ineffective¹. As recognised in your letter to us, the Trust has recently revised its risk assessment approach to align with NICE Guidelines² and NHS England’s recommendations. This approach emphasises addressing patient needs rather than predicting future risk through the previously used ‘low/medium/high’ categorisation.” Source location Response from Surrey and Borders Partnership NHS
Open published response
26 Sep 2024 Charne Nikita Petit · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Detention of patients in general hospitals without a section while awaiting a mental health bed View source Lack of mental health hospital beds for assessment, medical review and treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charne Nikita Petit · 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
Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Detention of patients in general hospitals without a section while awaiting a mental health bed
Wider context from the report “(2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed , because they cannot be placed under section unless a mental health bed is available.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health hospital beds for assessment, medical review and treatment
Wider context from the report “(1) Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed. This is what a s2 admission is designed to effect. The lack of a bed in a mental health hospital denied Ms Petit this opportunity for optimal treatment.
” 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 Embed Operational Pressures Escalation Level procedures, including daily bed-capacity meetings to manage demand and support people awaiting admission.
Verbatim wording from the response “At a national level, this lack of bed availability is a matter for the Secretary of State for Health to address. Nonetheless, the Trust and our staff work to provide appropriate treatment in the context of the impact of bed shortages to those who require inpatient treatment. In response to the national shortage of mental health acute beds, the Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice. This is an NHS England framework which provides a consistent approach to managing demand across the health and social care system and a procedure for managing surges in demand for inpatient mental health beds. OPEL bed meetings are convened every morning by locality” Source location Response from Surrey and Borders Partnership
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 collaborative Mind and Body Transformation improvement work with acute-care partners to integrate physical and mental healthcare for people awaiting or receiving acute hospital care.
Verbatim wording from the response “Since Charne’s sad death in May 2023, the Trust has embarked on collaborative improvement work with our acute care partners through the Mind and Body Transformation as part of the Trust Provider Collaborative (which consists of SaBP, Ashford and St Peter’s, Royal Surrey County Hospital and also includes East Surrey Hospital, Epsom General and Frimley Park Hospital). This work is in recognition of the challenges the system faces to support people safely whilst they may be awaiting a mental health bed or be in the acute hospital with both physical and mental health needs. The programme has been designed to better integrate physical and mental healthcare, and support for people attending acute hospitals with a combination of needs, by improving outcomes, flow and experience of those with mental health needs, their carers and families.” Source location Response from Surrey and Borders Partnership
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 Detention under the Mental Health Act in an acute hospital can occur only with the acute Trust’s agreement.
Verbatim wording from the response “Therefore, where a person is admitted to the acute hospital and does not consent to remain there on a voluntary basis, steps are taken to detain the person under the Mental Health Act to a bed at the acute hospital wherever possible. This action can only be taken with the agreement of the acute Trust. The section under the Mental Health Act is commenced at the acute hospital and transfer to an inpatient mental health setting will take place as soon as a bed is available. Anyone detained under the Mental Health Act in an acute hospital would have a Responsible Clinician, who is a Consultant Psychiatrist. This ensures that medication can be introduced, where appropriate, and their response to treatment monitored. They also continue to benefit from the multi-disciplinary assessment and treatment of the Psychiatric Liaison Services while an inpatient mental health bed is awaited.” Source location Response from Surrey and Borders 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 NHS England is considered the body most appropriately placed to address the national mental health inpatient bed shortage.
Verbatim wording from the response “While working within a legal framework acknowledged by the Government to be in need of reform, we and our partners within the health and care system must also react to increasing numbers of people presenting in crisis. I remain committed to continually improving the way in which we provide mental health care to those served by the Trust despite the bed availability difficulties faced and would very much welcome the resolution of this issue at a national level. I note that the PFD report has also been sent to NHS England who are most appropriately placed to address this issue nationally.” Source location Response from Surrey and Borders Partnership
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 Responsibility for addressing the national shortage of mental health inpatient beds rests with the Secretary of State for Health.
Verbatim wording from the response “At a national level, this lack of bed availability is a matter for the Secretary of State for Health to address. Nonetheless, the Trust and our staff work to provide appropriate treatment in the context of the impact of bed shortages to those who require inpatient treatment. In response to the national shortage of mental health acute beds, the Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice. This is an NHS England framework which provides a consistent approach to managing demand across the health and social care system and a procedure for managing surges in demand for inpatient mental health beds. OPEL bed meetings are convened every morning by locality” Source location Response from Surrey and Borders Partnership
Open published response
18 Sep 2024 Helen Jane Kerr · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Failure to access relevant police records during assessment View source Failure to inform refuge workers of a relevant police presentation View source Lack of evidenced efficacy of implemented changes View source Failure to appropriately assess declining mental health information and provide timely mental health referrals View source Lack of timely out-of-hours information sharing between police, mental health agencies and adult safeguarding View source Failure to assess and act on risk to the public View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Helen Jane Kerr · 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
Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to access relevant police records during assessment
Wider context from the report “(2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform refuge workers of a relevant police presentation
Wider context from the report “(4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidenced efficacy of implemented changes
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess declining mental health information and provide timely mental health referrals
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely out-of-hours information sharing between police, mental health agencies and adult safeguarding
Wider context from the report “(3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and act on risk to the public
Wider context from the report “(2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk.
” 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 Test and roll out the digital Psychiatric Liaison Service assessment template with mandatory collateral-information fields and recorded reasons when information is unavailable.
Verbatim wording from the response “Further progress has been made in the development of a digital solution which will more robustly support the obtaining and recording of collateral information. A collateral history section has been added to the new PLS assessment template as a mandatory field. There is also a section where a reason must be provided if collateral information has not been obtained. The roll out of the new assessment template has been expedited to the Psychiatric Liaison Services and is currently being tested in two of our PLS services as part of our quality improvement approach and in order to trial clinical effectiveness. Full roll out is anticipated to be completed by the end of 2024.” Source location Response from Surrey and Borders Partnership
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 Use revised SBAR documentation to include carer and family views in decision-making.
Verbatim wording from the response “In addition to the above improvements, the Trust website was updated to provide detail to external professionals on the different routes for emergency, urgent and routine referrals. There is now greater collaboration with family and referrers, supported by changes to the SBAR (a structured tool for communicating and sharing information which requires recording of the Situation, Background, Assessment and Recommendation) to now include carer/family views which are factored into decision making.” Source location Response from Surrey and Borders Partnership
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 Update, ratify and disseminate the Psychiatric Liaison Service operating policy on obtaining collateral information and using practitioner support during lone working.
Verbatim wording from the response “During the inquest, the Trust also provided written evidence of improvements that had been implemented in the Psychiatric Liaison Service (“PLS”), particularly in relation to ensuring that collateral information is obtained. The PLS Standard Operational Policy (“SOP”) has now been updated to reflect these changes. This document was ratified and disseminated to all PLS teams in September 2024. The improvements include an emphasis on identifying the relevant sources of collateral information and the process that should be followed when a clinician is unable to access relevant collateral information. It outlines that, in these circumstances, consideration should be given to delaying discharge to allow further attempts to obtain collateral and formulate a safe discharge plan.” Source location Response from Surrey and Borders Partnership
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 Test new Single Point of Access procedures and apply quality-control review to assess consistent implementation and identify service improvements.
Verbatim wording from the response “The implementation of the new SPA procedures is currently subject to testing in line with our quality improvement approach. The aim of this is to provide assurance that the new processes are applied consistently and are embedded. We have introduced a quality control process within SPA and the ongoing testing and review will allow us to identify other ways in which the service can be optimised. As part of this work, we are taking additional steps to enhance the out of hours offer.” Source location Response from Surrey and Borders Partnership
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 Deliver training across i-access services on recognising psychosis and making timely mental-health referrals.
Verbatim wording from the response “Further learning is reflected in the production of training which has been developed and rolled out across our i-access services. This focuses on recognising signs and symptoms of psychosis and the importance of a timely referral to mental health services for assessment. To date, 86% of relevant staff have viewed this training and it is planned that the remaining staff (who have been unable to do so due to absence from work) will have viewed this by 15 November 2024.” Source location Response from Surrey and Borders Partnership
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 random dip audits of assessments across the five Psychiatric Liaison Services to monitor collateral-information practice.
Verbatim wording from the response “A random dip audit of assessments across our five PLS services in September 2024 confirms a trajectory of improvement in that collateral information was sought in 90% of cases, as compared to 80% when the same audit was conducted in June 2024.” Source location Response from Surrey and Borders Partnership
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 senior oversight of Single Point of Access triage and recording of referrer collateral information.
Verbatim wording from the response “In the PFD report, you highlighted that a considerable amount of evidence has been provided by the Trust of the changes around prescribing referrals into our services. In particular, the PFD report notes that referrals into the Single Point of Access (“SPA”) can now be made by voluntary agencies and new protocols require more senior oversight of triaging decisions and recording of collateral information from referrers.” Source location Response from Surrey and Borders Partnership
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Professionals and Crisis Lines provide the appropriate urgent information-sharing and crisis referral pathways, so SCARF need not provide crisis access.
Verbatim wording from the response “The PFD Report also outlines a concern that the Single Combined Assessment of Risk Form, known as a SCARF, does not enable information sharing between organisations out of hours. The purpose of a SCARF is to help police officers to record and raise safeguarding concerns and observations about the needs, vulnerabilities and risk issues relating to those who come into contact with the police. A SCARF is not designed to be used to access crisis support or obtain emergency assistance. If the police have concerns which require urgent attention or advice, there is a dedicated Professionals Line which operates 365 days a year, 24 hours a day.” Source location Response from Surrey and Borders Partnership
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 Surrey Police is responsible for addressing the other matters raised in the PFD report.
Verbatim wording from the response “The other matters within the PFD Report relate solely to Surrey Police and I will therefore allow that organisation to address those issues directly.” Source location Response from Surrey and Borders Partnership
Open published response
22 Dec 2023 Larry Stephen SPRIGGS · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Inadequate processes for managing incidents View source Failure to ensure passage of information between staff concerning patients’ care and treatment View source Inadequate arrangements for assessing and managing inpatients’ risk, including use of anti-anxiety medication View source Inadequate arrangements for managing and implementing intermittent observation View source See 1 more concern
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
Larry Stephen SPRIGGS · 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
Larry Stephen Spriggs died after falling from the window of his room at Farnham Road Hospital on 27 May 2021. The inquest identified concerns about the assessment and management of inpatient risk, the use of anti-anxiety medication, communication between staff, and the implementation and management of intermittent observations. The death was recorded as contributed to by neglect and caused or more than minimally contributed to by failures in implementing intermittent observations.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate processes for managing incidents
Wider context from the report “The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk.
Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms.
Passage of information between staff concerning patients care and treatment.
The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital.
Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure passage of information between staff concerning patients’ care and treatment
Wider context from the report “The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk.
Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms.
Passage of information between staff concerning patients care and treatment.
The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital.
Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate arrangements for assessing and managing inpatients’ risk, including use of anti-anxiety medication
Wider context from the report “The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk.
Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms.
Passage of information between staff concerning patients care and treatment.
The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital.
Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate arrangements for managing and implementing intermittent observation
Wider context from the report “The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk.
Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms.
Passage of information between staff concerning patients care and treatment.
The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital.
Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room.
” 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 Use twice-daily electronic SBAR updates and structured staff handovers, including daily safety reporting, to communicate safety-critical information.
Verbatim wording from the response “Measures have been introduced to improve the passage of information between staff across our inpatient wards. It is acknowledged that embedding change takes time and we are committed to continually improving our processes to ensure effective and timely communication of information.” Source location Response from Surrey and Boarders 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 Apply observation competency checks, prompt sheets, nurse-in-charge oversight and monthly supportive-observation audits on Victoria Ward.
Verbatim wording from the response “Observation competency checklists are completed at staff induction for all substantive and temporary staff working on Victoria Ward. An observation prompt sheet is provided to staff completing observations. The responsibility for overseeing observations lies with the nurse in charge. From June 2023, Victoria Ward introduced the Supportive Observations Audit Tool. This provides a quality assurance process for not only the policy compliance around supportive observations, but also in the wider context of MDT overview, clinical rationale, care planning and the views of the person. Audits of ten people in the care of the Victoria Ward are carried out on a monthly basis.” Source location Response from Surrey and Boarders 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 Test and evaluate the digital supportive-observation and therapeutic-engagement recording solution before deciding on wider rollout.
Verbatim wording from the response “In addition, and in co-production with the Victoria Ward clinical team and the Quality Improvement team, a digital solution has been developed for the recording of supportive observations and therapeutic engagement. It is intended that this will be tested and evaluated for its impact on safety prior to a decision about wider roll out across the organisation as part of the current Inpatient Improvement Plan.” Source location Response from Surrey and Boarders 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 Adopt the Patient Safety Incident Response Framework to strengthen incident learning, transparency and involvement of affected people.
Verbatim wording from the response “In addition, the Trust has now adopted the Patient Safety Incident Response Framework (PSIRF) which is part of the approach to patient safety that is described within the National Patient Safety Strategy. PSIRF will enhance our safety and learning culture by creating much stronger links between patient safety incidents and learning, working in collaboration with those affected by the incident. In turn, this fosters a culture of transparency and openness amongst staff in reporting incidents and engagement in implementing improvement to embed learning.” Source location Response from Surrey and Boarders 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 Implement recommendations from the national therapeutic-observation and engagement review.
Verbatim wording from the response “There is a national observation improvement programme underway and the Trust is leading one of the work streams around workforce and training. The programme is led by the National Mental Health and Learning Disability Nurses Directors Forum who are reviewing therapeutic observations and engagement practice. The Trust is part of the Project Board and will be implementing recommendations from the review alongside other mental health trusts.” Source location Response from Surrey and Boarders 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 Use the new Risk Assessment Template to formulate inpatient risk and guide medication and other therapeutic decisions.
Verbatim wording from the response “Further to NICE guidelines indicating a change from the global stratification of risk into “low, medium or high”, the Trust developed and successfully piloted a new Risk Assessment Template which went live in January 2024. This, together with the mandatory suicide prevention training for clinicians which was introduced in November 2022, has improved our ability to assess inpatient risk.” Source location Response from Surrey and Boarders Partnership NHS Foundation Trust
Open published response
22 Dec 2023 Barbara Ann WOODMAN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 8 Inaccessibility of primary care records to secondary mental health services View source Delays in considering SCARF information View source Failure to communicate relevant SCARF information to family View source Failure of the out-of-hours SCARF process to provide timely effective information transfer View source Failure to produce a clear holistic care and crisis contingency plan View source Lack of a unified record-keeping system for sharing patient information View source Breakdowns in communication between inpatient staff and the CMHT View source Failure to gather relevant collateral history while respecting patient confidentiality View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Barbara Ann WOODMAN · 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
Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of primary care records to secondary mental health services
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████.
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services . This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in considering SCARF information
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant SCARF information to family
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur . The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the out-of-hours SCARF process to provide timely effective information transfer
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce a clear holistic care and crisis contingency plan
Wider context from the report “c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community . Although not causative of the death and I noted ████████’s very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a unified record-keeping system for sharing patient information
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS , including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians .
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdowns in communication between inpatient staff and the CMHT
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP .
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to gather relevant collateral history while respecting patient confidentiality
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████ .
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” 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 Surrey County Council and Surrey Police to address joint SCARF procedures.
Verbatim wording from the response “We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be carrying out a review as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.” Source location Surrey Council and Surrey NHS Joint Response
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 Carry out a detailed cross-agency review of the SCARF process, including information sharing, confidentiality and consent.
Verbatim wording from the response “We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be carrying out a review as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.” Source location Surrey Council and Surrey NHS Joint Response
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 crisis, professionals’ and Emergency Duty Team arrangements provide appropriate out-of-hours responses, so SCARFs are unnecessary for immediate referrals.
Verbatim wording from the response “A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This allows emergency services to request critical information in an immediate timeframe to help inform decisions about people they have come into contact with.” Source location Surrey Council and Surrey NHS Joint Response
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 NHS England is best placed to address the absence of a unified record-keeping system across NHS providers.
Verbatim wording from the response “In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.” Source location Surrey Council and Surrey NHS Joint Response
Open published response
Concerns raised 2 Failure to undertake a mental health assessment following self-harm or suicidal ideation View source Failure to record suicidal ideation identified during emergency department care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryan John EVANS · 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
Ryan John EVANS died after being found hanging in the communal area of his accommodation on 3 April 2018. The concerns included that, despite evidence of self-harm and suicidal ideation, no mental health assessment was carried out at hospital, and that mental health information and referrals were not effectively documented or communicated during his time in police custody.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a mental health assessment following self-harm or suicidal ideation
Wider context from the report “An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation . Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded.
The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital.
These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.”
Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation .
The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point. ’
I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again.
The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record suicidal ideation identified during emergency department care
Wider context from the report “An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded.
The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital.
These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.”
Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation.
The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’
I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again.
The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment.
” 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 Update and ratify the Psychiatric Liaison Services Standard Operating Policy and referral criteria.
Verbatim wording from the response “As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October 2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. A sense of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context.” Source location Response from Surrey NHS
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 Continue reviewing Psychiatric Liaison Services referral criteria as part of continuous improvement.
Verbatim wording from the response “As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October 2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. A sense of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context.” Source location Response from Surrey NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing referral and assessment measures for mental health presentations were considered adequate, with timely response expected when a referral was received.
Verbatim wording from the response “In the PFD report, you highlighted a concern relevant to the Trust and Frimley Health NHS Foundation Trust (“Frimley”). In particular, you outline the additional evidence provided at the inquest by Frimley Health NHS Foundation Trust. We believe that the Trust did have adequate measures in place at the time of Mr Evans’ admission to Frimley Park Hospital and that, had we received a referral, we would have responded in a timely manner.” Source location Response from Surrey NHS
Open published response
Concerns raised 5 Lack of provision of mental health care for people waiting for gender-affirming treatment View source Delays in access to gender-affirming healthcare View source Lack of clarity for Primary Care clinicians supporting young transgender individuals View source Lack of clarity for mental health clinicians supporting young transgender individuals View source Lack of knowledge and training for managing and offering mental health care to transgender people View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alice LITMAN · 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
Alice Litman, a 20-year-old trans female, was found dead on 26 May 2022 after a descent from height. The report raised concerns about mental-health training and support for transgender people, delays in accessing gender-affirming healthcare, and insufficient clarity and provision of care while awaiting treatment.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of provision of mental health care for people waiting for gender-affirming treatment
Wider context from the report “c) The lack of provision of mental health care for those waiting for gender affirming treatment .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to gender-affirming healthcare
Wider context from the report “b) The delays in access to gender affirming healthcare .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for Primary Care clinicians supporting young transgender individuals
Wider context from the report “d) The lack of clarity for clinicians who are in place to support young transgender individuals in Primary Care
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for mental health clinicians supporting young transgender individuals
Wider context from the report “e) The lack of clarity for clinicians who are in place to support young transgender individuals in the Mental Health Setting .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and training for managing and offering mental health care to transgender people
Wider context from the report “a) The knowledge and training for those in the mental health setting for managing and offering care to those in the transgender community .
” 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 Share the strengthened transgender-support policy through the staff Communications e-bulletin.
Verbatim wording from the response “We recognise the need to work effectively with community and third sector organisations to enable appropriate and effective signposting. One way in which we do this is through our involvement with the Adult Mental Health Alliance, bringing together experts from across the sector and presenting an opportunity to share ideas around improving care pathways for young transgender individuals. The Trust has a Supporting People who are Trans Policy which contains an extensive list of third sector organisations. Following the meeting with Alice’s parents, the Trust is reviewing, and adding to, this list of organisations. The strengthened policy will be shared in the Communications e-bulletin sent to all staff and incorporated into the mandatory training offer.” Source location Response from Surrey and Borders 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 Incorporate the strengthened transgender-support policy into the mandatory training offer.
Verbatim wording from the response “We recognise the need to work effectively with community and third sector organisations to enable appropriate and effective signposting. One way in which we do this is through our involvement with the Adult Mental Health Alliance, bringing together experts from across the sector and presenting an opportunity to share ideas around improving care pathways for young transgender individuals. The Trust has a Supporting People who are Trans Policy which contains an extensive list of third sector organisations. Following the meeting with Alice’s parents, the Trust is reviewing, and adding to, this list of organisations. The strengthened policy will be shared in the Communications e-bulletin sent to all staff and incorporated into the mandatory training offer.” Source location Response from Surrey and Borders 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 Review and expand the third-sector organisation list in the Supporting People who are Trans Policy.
Verbatim wording from the response “We recognise the need to work effectively with community and third sector organisations to enable appropriate and effective signposting. One way in which we do this is through our involvement with the Adult Mental Health Alliance, bringing together experts from across the sector and presenting an opportunity to share ideas around improving care pathways for young transgender individuals. The Trust has a Supporting People who are Trans Policy which contains an extensive list of third sector organisations. Following the meeting with Alice’s parents, the Trust is reviewing, and adding to, this list of organisations. The strengthened policy will be shared in the Communications e-bulletin sent to all staff and incorporated into the mandatory training offer.” Source location Response from Surrey and Borders 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 Develop co-produced mandatory, age-specific training for staff supporting transgender people, including clinicians working with under-18s and young adults.
Verbatim wording from the response “Together with the Chief Nursing Officer, I met with Alice’s parents in December 2023 to discuss the steps that the Trust can take to implement learning from Alice’s death and the subsequent inquest. This included discussion about a mandatory training package for all staff which will help them in their approach with people from the transgender community. Recognising the importance of consultation with those with lived experience and their families, ████████ have kindly agreed to co-produce this with the Trust and other relevant external agencies. We would like to thank them for the information they have already sent us around organisations we may wish to work with. We also acknowledge that, for the training to remain impactful, it will require regular review and update.” Source location Response from Surrey and Borders Partnership NHS Foundation Trust
Open published response
15 Jun 2022 William SAVORY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of staff awareness of the requirement to commence missing person procedures immediately 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
William SAVORY · 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
William Savory, a 31-year-old man, was found deceased on 27 January 2020 after leaving a psychiatric hospital and not returning at the agreed time. His death was due to acute fatal alcohol toxicity after drinking a significant amount of alcohol. The Coroner was concerned that not all staff were aware that missing person procedures should be commenced immediately.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the requirement to commence missing person procedures immediately
Wider context from the report “SABP’s written policies require staff to commence missing person procedures immediately, yet the Coroner is concerned that not all staff are aware of this requirement . The Coroner therefore invites SABP to consider additional training or other measures to raise awareness of this requirement amongst all levels of staff including Health Care Assistants.
” Open source report
7 Mar 2022 Melanie Jane ELMS · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Failure to follow and maintain an adequate post-discharge care package View source Lack of a missing-person plan with timeframes and escalation steps for leave View source Inadequate risk assessment prior to leave View source Lack of additional planning for changes in circumstances View source Failure to properly complete the walk book View source Failure to record risk assessments prior to leave View source See 3 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.
×
AI-generated summary
Melanie Jane ELMS · 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
Melanie Jane Elms, an informal patient at the Abraham Cowley Unit with a history of schizo-affective disorder and suicidal attempts, left the unit on day leave on 30 January 2018 and was fatally struck by a train. The inquest identified that a mandatory pre-leave risk assessment was not carried out, concerns raised by her husband were not properly recorded or acted upon, and her leave was not adequately documented or managed. The report also raised concerns about the failure to provide the planned care package and the absence of a missing-person plan and contingency planning.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow and maintain an adequate post-discharge care package
Wider context from the report “1. The care package arranged for Melanie following discharge from lengthy in-patient admission was not followed and was altered to something which the treating doctor did not consider adequate .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a missing-person plan with timeframes and escalation steps for leave
Wider context from the report “4. There was no missing person plan in place with timeframe and steps of escalation for Melanie’s leave .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate risk assessment prior to leave
Wider context from the report “5. Risk assessment prior to leave was not adequate .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of additional planning for changes in circumstances
Wider context from the report “3. There was no extra planning for changes in circumstances : Melanie faced never being allowed to return to family life with her husband and son due to Child In Need proceedings; changes in medication and less support from family due to the Social Services requirements.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete the walk book
Wider context from the report “2. The walk book was not properly completed .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record risk assessments prior to leave
Wider context from the report “6. Risk assessment prior to leave was not recorded .
” Open source report
31 Jan 2022 OSKAR MILES NASH · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 15 Inadequate information and record sharing before EHCP school placements View source Lack of mandatory Autism training for Education and SEN staff View source Lack of training and monitoring programme for EHCP medical advisers View source Failure to establish changed child mental health triage practices in written guidance View source Failure of the threshold of needs document to reflect risks for autistic children View source Lack of specific safeguarding guidance for children with disabilities View source Lack of clarity about schools’ information-sharing powers and duties View source Lack of clinician understanding of EHCP medical advice responsibilities View source Inappropriate closure or referral of child mental health referrals View source Lack of monitoring of access to clinical teams and referral outcomes View source Lack of comprehensive, relevant and mandatory Autism training across state agencies View source Insufficient process, guidance and oversight for effective post-death investigations View source Automatic categorisation of routine referrals as low risk View source Lack of mandatory Autism training for Children’s Services staff View source Lack of mandatory Autism training for child mental health referral triage staff View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 5
Position
Routine referrals are not automatically treated as low risk; they are screened as low risk only after assessment and confirmation of protective factors.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Existing referral monitoring tracks referrals received and onward referrals to clinical teams, with activity reviewed through the executive accountability committee.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing triage and treatment processes establish goals, measure intervention effectiveness, and provide progress and outcome updates to referrers and GPs.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing closure safeguards require engagement with the GP, information for families, and consideration of safeguarding before referrals are closed.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing DCO oversight, regular meetings with Trust medical advisers, and urgent-query support provide monitoring of clinicians’ EHCP responsibilities.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 4 more positions
×
AI-generated summary
OSKAR MILES NASH · 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
Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate information and record sharing before EHCP school placements
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing . On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP . I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents, and any data protection ramifications this may have.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Education and SEN staff
Wider context from the report “The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training and monitoring programme for EHCP medical advisers
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process. I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish changed child mental health triage practices in written guidance
Wider context from the report “I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the threshold of needs document to reflect risks for autistic children
Wider context from the report “Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support , as was the case for Oskar.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific safeguarding guidance for children with disabilities
Wider context from the report “I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism , and the approach to be taken by agencies to parents and families.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about schools’ information-sharing powers and duties
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing. On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents , and any data protection ramifications this may have.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of EHCP medical advice responsibilities
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process . I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate closure or referral of child mental health referrals
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies . In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of access to clinical teams and referral outcomes
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies. In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive, relevant and mandatory Autism training across state agencies
Wider context from the report “At the prevention of future deaths hearing, I heard evidence of more training being available, but also of an ongoing absence of comprehensive, relevant and mandatory training .
I was told that the National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children .
I am concerned that this poses an ongoing risk to autistic children and their ability to access the services they require for their support, welfare, and safeguarding.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient process, guidance and oversight for effective post-death investigations
Wider context from the report “Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation , which should not be dependent on the inquest process, is achieved in all cases.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of routine referrals as low risk
Wider context from the report “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk” . I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Children’s Services staff
Wider context from the report “The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, including Social Workers and other Team members, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for child mental health referral triage staff
Wider context from the report “The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis .
” 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 Apply harm reviews to routine referrals waiting over four weeks and review continuing waits every four weeks until triage.
Verbatim wording from the response “If a routine referral has been waiting for over four weeks to be triaged, then it is now subject to a harm review. The child/young person and/or their family will be contacted as part of this, and there will be a conversation about what the current situation is and whether there are any increased risks. Following this review, the referral will either be categorised as being suitable and safe to remain in the routine referral waiting list, with safety netting advice being provided. Alternatively, if the risks have escalated, the referral will be triaged immediately and then referred on to an appropriate service.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 Require exceptional referral closure safeguards, including GP and family notification, continued-access information and consideration of safeguarding referral.
Verbatim wording from the response “Referrals will only be closed to the AAT without providing an onward referral in exceptional circumstances. This would typically be where the parent or carer does not engage in the triage process. Before a referral is closed a letter is sent to the parent / carer and the child / young person’s GP, this provides the number to call should they wish to continue with the triage process, or if their circumstances change. Therefore, no referral is closed without the Trust having engaged with the GP and providing the parent / carer with information on how to get support if their circumstances change. Where there is no engagement from the parent or carer, a safeguarding referral must be considered.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 Deliver mandatory Autism Awareness training to CYPS staff, initially prioritising the Access and Advice Team.
Verbatim wording from the response “Our response
A new “Autism Awareness” half-day training course, provided by the Association for Psychological Therapies (APT), has been added to the mandatory training matrix for all CYPS staff. The course is designed to raise staff’s knowledge and awareness of the importance of autism and covers issues such as:” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and approve the Standard Operating Procedure manual to reflect new referral triage practices.
Verbatim wording from the response “Concern 4
I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 induction, refresher and continuing professional development training on EHCP advice and completion for relevant Developmental Paediatrics and CAMHS staff.
Verbatim wording from the response “Training
All Developmental Paediatrics new starters have induction on EHCP advice. CPD sessions are then provided on a monthly basis and these will include training on EHCPs where there are changes or learning to be shared.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 treatment goals, measure intervention effectiveness against outcome measures, and provide progress and completion summaries to referrers and GPs.
Verbatim wording from the response “When referrals are made, the referrer and family will have expectations of what treatment should be provided. Through triage, we refine our understanding and match our support in line with the child / young person’s emerging need(s). Treatment goals are then established and the effectiveness of interventions are measured against outcome measures.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 Hold regular meetings between Designated Clinical Officers and Trust medical advisors to disseminate EHCP guidance, resolve challenges and provide quality assurance.
Verbatim wording from the response “Monitoring
Local Authority DCOs are employed by Clinical Commissioning Groups (CCGs) and have a specific role focused on special educational needs (SEN). They help CCGs oversee the care and treatment that is given to SEN children and give guidance on completion of EHCP documents and support EHCP tribunals.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 Monitor referrals reaching clinical teams and review clinical and non-clinical referral activity through the monthly accountability committee.
Verbatim wording from the response “The Trust monitors the total number of referrals that are received by the AAT and the number of referrals that are subsequently referred onto clinical teams, these are:
- Neurodevelopmental Pathway
- Community CAMHS and Primary Mental Health Teams
- Crisis Intervention Services including Hope and Extended Hope
- Learning Disability Service
- Eating Disorder Service
- Care Experienced Services” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 Routine referrals are not automatically treated as low risk; they are screened as low risk only after assessment and confirmation of protective factors.
Verbatim wording from the response “I have been told that the routine referrals are automatically categorised as “low risk”. … It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 referral monitoring tracks referrals received and onward referrals to clinical teams, with activity reviewed through the executive accountability committee.
Verbatim wording from the response “There is a lack of specific monitoring of what proportion of referred children reach a clinical team.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 triage and treatment processes establish goals, measure intervention effectiveness, and provide progress and outcome updates to referrers and GPs.
Verbatim wording from the response “There is a lack of specific monitoring of the extent to which the outcomes match the expectations of the referrers” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 closure safeguards require engagement with the GP, information for families, and consideration of safeguarding before referrals are closed.
Verbatim wording from the response “Referrals will only be closed to the AAT without providing an onward referral in exceptional circumstances. This would typically be where the parent or carer does not engage in the triage process. Before a referral is closed a letter is sent to the parent / carer and the child / young person’s GP, this provides the number to call should they wish to continue with the triage process, or if their circumstances change. Therefore, no referral is closed without the Trust having engaged with the GP and providing the parent / carer with information on how to get support if their circumstances change. Where there is no engagement from the parent or carer, a safeguarding referral must be considered.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
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 DCO oversight, regular meetings with Trust medical advisers, and urgent-query support provide monitoring of clinicians’ EHCP responsibilities.
Verbatim wording from the response “Monitoring
Local Authority DCOs are employed by Clinical Commissioning Groups (CCGs) and have a specific role focused on special educational needs (SEN). They help CCGs oversee the care and treatment that is given to SEN children and give guidance on completion of EHCP documents and support EHCP tribunals.” Source location 2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
Open published response
21 Apr 2021 MARY NABILIA GWANYAMA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Difficulty accessing community treatment and support after out-of-area placement View source Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based View source Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning View source Discharge from the Home Treatment team on ineffective medication View source Failure to provide coherent community-care planning and care-coordinator involvement at discharge View source Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge View source Lack of policy governing frequency of community review for risk and medication compliance View source Failure to follow the Care Programme Approach during discharge View source Premature discharge before the effectiveness of prescribed medication is adequately observed View source Failure to undertake and record formal pre-discharge risk assessments View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
MARY NABILIA GWANYAMA · 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
Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty accessing community treatment and support after out-of-area placement
Wider context from the report “7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her . There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based
Wider context from the report “4. The informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Mary of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk . The risk assessments were not sufficiently rigorous and evidence based .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning
Wider context from the report “1. Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan as to what would happen after the Travel Lodge placement ended . There is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge from the Home Treatment team on ineffective medication
Wider context from the report “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coherent community-care planning and care-coordinator involvement at discharge
Wider context from the report “6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community . Her care coordinator was not involved in the discharge planning . The CPA was not followed.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge
Wider context from the report “2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy governing frequency of community review for risk and medication compliance
Wider context from the report “7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Care Programme Approach during discharge
Wider context from the report “5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Premature discharge before the effectiveness of prescribed medication is adequately observed
Wider context from the report “5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication . This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA (“Care Programme Approach”) was not followed.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and record formal pre-discharge risk assessments
Wider context from the report “3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit.
” 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 Recruit and deploy a Lead Nurse for Quality and Practice to improve inpatient care plans and risk assessments.
Verbatim wording from the response “In addition to this, in April 2021 we recruited a Lead Nurse for Quality and Practice, specifically for inpatient services. Part of her role is around ensuring the quality of our inpatient care plans and risk assessments and identifying areas for improvement. We have also delivered a significant amount of Suicide Prevention Training across our clinical services.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 SBAR-based RAG ratings in community-team multidisciplinary reviews to determine risk-based contact frequency.
Verbatim wording from the response “Since Ms Gwanyama’s death, our community teams have implemented the SBAR process during their MDT reviews to RAG rate patients and determine how often they should be seen in the community based on their assessed risk. People’s risk changes and people will move through the different levels of risk-based contact. If a patient is rated Red, this requires weekly contact. If a patient is rated Amber, this requires fortnightly contacted. If a patient is rated Green, then the contact ranges from monthly” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Update the CMHRS policy to require ongoing contact during transfers between Trusts, based on SBAR/RAG-rated need, until transfer completion.
Verbatim wording from the response “Our CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. Our policy is going to ensure that, where a patient is in transition to a neighbouring Trust, we will still provide face to face or telephone/virtual contact as we would base this on the SBAR/RAG rating and identified frequency of need, until the transfer process is complete. If the patient is residing in an area which is relatively local to the team and easily accessible by travel, then we would expect the team to travel to visit the patient if necessary.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Deliver training on risk assessment, risk factors, care-plan links and use of the SystmOne risk-assessment tool.
Verbatim wording from the response “In ████████ letter dated 24th March 2021, he outlined the significant improvements that have been made regarding risk assessments since Ms Gwanyama’s death. In particular, he highlighted that a new risk assessment node has been developed on SystmOne, which was rolled out in October 2019 together with a training package focussed on:” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Implement SBAR in Home Treatment Team practice and update its operational policy to strengthen multidisciplinary medical-review documentation and decision-making.
Verbatim wording from the response “As explained in ████████ letter dated 24th March 2021, consideration is given at the daily HTT handover meetings, where there is a doctor present, as to how to best meet people’s needs within their overall care plan. It should also be noted that in addition to the handover meetings, each HTT holds weekly clinical reviews attended by the full multi-disciplinary team. During this review, each person on the HTT caseload is systematically reviewed to determine the appropriateness of the existing care plan, risk management plans including medical review and discharge plans.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 the SystmOne risk-assessment node to support structured, evidence-based risk assessments.
Verbatim wording from the response “In ████████ letter dated 24th March 2021, he outlined the significant improvements that have been made regarding risk assessments since Ms Gwanyama’s death. In particular, he highlighted that a new risk assessment node has been developed on SystmOne, which was rolled out in October 2019 together with a training package focussed on:” Source location 2021-0117-Response-from-Surrey-and-Borders-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 local team visits when transitioning patients are nearby and accessible, where necessary.
Verbatim wording from the response “Our CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. Our policy is going to ensure that, where a patient is in transition to a neighbouring Trust, we will still provide face to face or telephone/virtual contact as we would base this on the SBAR/RAG rating and identified frequency of need, until the transfer process is complete. If the patient is residing in an area which is relatively local to the team and easily accessible by travel, then we would expect the team to travel to visit the patient if necessary.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Refer patients with urgent needs to their local HTT or crisis service for immediate care and risk assessment.
Verbatim wording from the response “Further, where a patient’s needs are considered urgent, then the CMHRS will be guided to make a referral to the patient’s local HTT/Crisis service (as this does not require a CPA transfer), to ensure their immediate care needs are met and risks assessed and appropriately supported.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Add weekly audits of discharge checklists to verify completion and close the learning loop.
Verbatim wording from the response “Weekly audits of risk assessments and care plans are conducted by Senior Matrons in ACU and Farnham Road Hospital. We also have in place a discharge checklist, to include whether a risk assessment has been completed prior to discharge. These checklists have been in place for some time; however, they are not routinely audited. We are therefore going to add to the weekly audits a review of the discharge checklist, to ensure they are being completed appropriately and the learning loop closed.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Risk Assessment and Management Policy to guide staff in risk assessment and management.
Verbatim wording from the response “We are also reviewing our Risk Assessment and Management Policy to support and guide our staff in how to be confident in risk assessments risk and management.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Update CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.
Verbatim wording from the response “The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama being discharged from the Abraham Cowley Unit and, given she was homeless at the time and her housing situation was uncertain, such a meeting should have taken place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational Protocol will be updated to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge.” Source location 2021-0117-Response-from-Surrey-and-Borders-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 Medical review decisions remain risk- and needs-led through multidisciplinary processes rather than being governed by a fixed post-discharge Consultant Psychiatrist review mandate.
Verbatim wording from the response “Senior clinicians within the Trust have considered this issue, and our need to be agile to respond to people with differing needs. For that reason, the decision as to whether a person under HTT requires a medical review is risk and needs led within the context of a multi-disciplinary approach which includes a Consultant Psychiatrist. (It should however be noted that it is already mandated that a patient must follow up with community services within 72 hours of discharge from hospital, within an overall multi-disciplinary approach.)” Source location 2021-0117-Response-from-Surrey-and-Borders-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 A policy cannot prevent vulnerable patients from being discharged into homelessness because discharge depends on circumstances beyond the Trust’s control.
Verbatim wording from the response “Whilst we fully appreciate your concerns about no policy being in place, it is unfortunately not possible for the Trust to have a policy in place that prevents patients from being discharged into homelessness from our inpatient units. The onus is our duty to engage appropriately with the statutory referral to District and Borough Councils’ Housing Departments to find a homeless person settled accommodation. The pre-discharge planning would also involve our homelessness” Source location 2021-0117-Response-from-Surrey-and-Borders-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 District and Borough Housing Departments are responsible for finding settled accommodation following the Trust’s statutory referral of homeless patients.
Verbatim wording from the response “Whilst we fully appreciate your concerns about no policy being in place, it is unfortunately not possible for the Trust to have a policy in place that prevents patients from being discharged into homelessness from our inpatient units. The onus is our duty to engage appropriately with the statutory referral to District and Borough Councils’ Housing Departments to find a homeless person settled accommodation. The pre-discharge planning would also involve our homelessness” Source location 2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Open published response
9 Dec 2020 Kimberley Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Lack of written processes for managing informal patients assessed as too high risk to leave the unit View source Lack of written procedures addressing intermittent observations when informal patients request to leave the unit View source Lack of written risk-assessment procedures for informal patients requesting to leave the unit View source Alcohol detoxification protocols lacking specific care plans on mental health wards View source Lack of a written timeframe for reporting informal patients missing when they fail to return at the agreed time View source Alcohol detoxification protocols lacking minimum monitoring on mental health wards View source Alcohol detoxification protocols lacking management of leave requests during treatment View source Lack of written procedures for recording assessments and decisions on informal patients’ requests to leave the unit View source Lack of a written timeframe for reporting detained patients missing when they fail to return at the agreed time View source Lack of written risk-management plans for informal patients leaving the unit View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kimberley Smith · 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
Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written processes for managing informal patients assessed as too high risk to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written procedures addressing intermittent observations when informal patients request to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written risk-assessment procedures for informal patients requesting to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Alcohol detoxification protocols lacking specific care plans on mental health wards
Wider context from the report “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation,
‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’
The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans , minimum monitoring or the management of leave request during treatment.
It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written timeframe for reporting informal patients missing when they fail to return at the agreed time
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Alcohol detoxification protocols lacking minimum monitoring on mental health wards
Wider context from the report “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation,
‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’
The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment.
It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Alcohol detoxification protocols lacking management of leave requests during treatment
Wider context from the report “During the course of the inquest the court also heard that following Miss Smith’s death SABP carried out a Serious Incident investigation which resulted in the following recommendation,
‘To develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.’
The court heard that a protocol has been developed to manage the medical aspects of alcohol detoxification but does not cover care plans, minimum monitoring or the management of leave request during treatment.
It is of concern that these aspects of the recommendation remain outstanding and consideration should be given to implementing them as a matter of urgency.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written procedures for recording assessments and decisions on informal patients’ requests to leave the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written timeframe for reporting detained patients missing when they fail to return at the agreed time
Wider context from the report “2. There is no clear written policy/procedure on the following:
- The timeframe for reporting detained patients to the police as missing persons if they fail to return at the agreed time.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written risk-management plans for informal patients leaving the unit
Wider context from the report “1. There is no clear written policy/procedure on the following:
- The carrying out of risk assessments when informal patients request to leave the unit;
- The relevance of an informal patient being on intermittent observations when they request to leave the unit;
- The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
- The risk management plans to put in place when informal patients do leave the unit;
- The recording of assessments and decisions relation to requests made by informal patients to leave the unit;
- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
” 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 Complete guidance on alcohol detoxification for people admitted to inpatient wards.
Verbatim wording from the response “Our response:
The Trust has now completed its guidance regarding “Alcohol detoxification for people admitted to inpatient wards”.” Source location 2020-0279-Response-from-Surrey-and-Borders-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 Train and support inpatient staff to implement the alcohol-use-disorder guidelines through collaboration between detoxification nurses and inpatient Advanced Clinical Practitioners.
Verbatim wording from the response “Once complete, i-access detoxification nurses will work with the inpatient Advanced Clinical Practitioners to train and support inpatient staff to put the guidelines into practice.” Source location 2020-0279-Response-from-Surrey-and-Borders-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 Roll out a competency framework to train staff on the new and updated leave policies and their practical application.
Verbatim wording from the response “Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.” Source location 2020-0279-Response-from-Surrey-and-Borders-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 Update the Section 17 Leave Policy and Absent Without Leave Policy with guidance on reporting patients missing after agreed leave.
Verbatim wording from the response “2. Policy/procedure on reporting patients as missing
In the PFD, you identified that there is no clear written policy/procedure on the timeframe for reporting patients to the police as missing persons if they fail to return at the agreed time.” Source location 2020-0279-Response-from-Surrey-and-Borders-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 Develop a standalone written policy governing informal-patient leave, including risk assessment, leave decisions, risk management, recording and missing-person reporting.
Verbatim wording from the response “Our response:
Guidance in relation to leave for informal patients is currently set out in the Trust’s Section 17 Leave Policy. The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients. The policy will aim to ensure that the right balance is struck between respecting the rights of informal patients and the need to protect people who may be vulnerable and at risk of harm to themselves. The policy will also require all leave for informal patients to be supported by the patient’s risk assessment and care plan. I have had sight of the new draft policy and am confident that it will cover all the issues that you have highlighted (as outlined above).” Source location 2020-0279-Response-from-Surrey-and-Borders-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 Develop guidelines for managing people with alcohol use disorders on mental health wards, covering withdrawal monitoring, leave, risk assessments and care planning.
Verbatim wording from the response “We are also developing new guidelines for “Management of People with Alcohol Use Disorders (AuDs) Admitted to Mental Health Wards”. The new guidelines cover the following: monitoring of patients during withdrawal and detoxification (both physical and mental health), leave, risk assessments and care planning.” Source location 2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
Open published response
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Review mental health training for emergency services, emergency departments, police and Trust staff to include proportionate coverage of Mental Health Act sections 17 and 18.
Verbatim wording from the response “The mental health training provided to emergency services, emergency department, police and SABP staff will be reviewed to include an overview of section 17 and 18 of the MHA. This should be proportionate to the frequency that each organisation is expected to come across these cases and this will be determined by each organisation.” Source location Sasha-Forster-R2019-01692
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 Hold a further stakeholder meeting to review achievements and identify additional actions or training needs, including dissemination of learning.
Verbatim wording from the response “To respond to the PFD, a meeting was held on the 01 July 2019 between a number of the key stakeholders named in the PFD. Below is a summary of the discussions and actions that were agreed moving forwards. A further meeting will be held to discuss and evidence dissemination of learning and training.” Source location Sasha-Forster-R2019-01692
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 Include a written-authority template in the AWOL policy, update the policy with PFD learning, and present it to the Policy Assurance Group by September 2019.
Verbatim wording from the response “If the person is known to frequent emergency departments, frequently call the emergency services, or frequent another place where professionals are present, early consideration should be given to providing those services with written authority to take the person into custody and return them to the ward (they should be supported by SABP, the Police, and ambulance services (NHS or private / secure), in doing this as appropriate).” Source location Sasha-Forster-R2019-01692
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 Develop and include a section 17 leave revocation template in the Trust’s section 17 leave policy.
Verbatim wording from the response “If the decision is made to revoke the person’s leave this should be documented in the person’s notes before the SABP section 18 form or any other paperwork is completed (this means it will be visible to others accessing the record on SystmOne). It is preferable for this to be documented by the clinician who makes the decision to revoke the leave.” Source location Sasha-Forster-R2019-01692
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 Explore Graphnet as an integrated care record providing organisations read-only access to legal status, risks and contemporaneous care plans.
Verbatim wording from the response “There is a long term goal to create a platform that will allow NHS organisations to have read only access to key information pulled from a service user’s internal record keeping platforms. Graphnet is currently being explored to provide an integrated care record across Surrey. This will potentially be able to show that a person is currently detained in hospital allowing other organisations to see their legal status, as well as associated risks. Were a system such as this in place in early 2017 this would have allowed staff at the acute hospitals to view Sasha’s legal status and contemporaneous care plans; this would have assisted their decision making and meant that the system would have had read only access to the notes from her interactions with other services.” Source location Sasha-Forster-R2019-01692
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 Draft a shared systemwide protocol for managing complex AWOL cases and work towards its finalisation.
Verbatim wording from the response “The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).” Source location Sasha-Forster-R2019-01692
Open published response
8 May 2018 Stephen Ian William Tidey · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to record the basis for reduced risk-of-self-harm assessments View source Lack of safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Ian William Tidey · 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
Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the basis for reduced risk-of-self-harm assessments
Wider context from the report “He was assessed by a member of the Criminal Liaison and Diversion Service (CLDS) on the same day and was initially assessed by them as being at risk of self-harm. The member of the CLDS subsequently telephoned the Home Treatment Team to discuss referring him to the service. Mr Tidey was then re-assessed by the same member of the CLDS who stated he appeared calmer and was no immediate risk to himself. No notes were recorded on the Police or Mental Health Service computer system to record how this assessment of reduced risk of self-harm had been reached.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team
Wider context from the report “On Friday 16th December 2016, Police were made aware that Mr Tidey had lost his job as a consequence of being charged with the offences and therefore that one of the contingent events highlighted in the MASH referral of 3.2.2016 as placing Mr Tidey at higher risk of self-harm had materialised. They therefore completed a further MASH referral form and this was emailed to the MASH hub at 15.40 and forwarded on to Waverley CMHRS at 16.41.
On Monday 19th December 2016 at 11.30am, Waverley CMHRS forwarded the MASH report to Guildford CMHRS, but then emailed again at 11.36am to state they noted Waverley CMHRS should actually follow up Mr Tidey. However, for reasons, which cannot be ascertained, no further action was taken. It is not possible to ascertain who the duty worker was who received the referral by email.
████████, Community Services Manager for South West Community Mental Health Recovery Service, stated in evidence that had he received Mr Tidey’s MASH referral on 16th December 2016, he would have taken action the same day, initially via a telephone triage assessment and then via the options available of HTT referral; EDT Mental Health Act Assessment, crisis planning with safe havens or CMHRS non-crisis support, as appropriate.
Evidence was given that there were no safeguards in place to check referrals were being acted upon, and that this remains the case.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standardised log across community mental health teams for recording received SCARF forms and resulting actions.
Verbatim wording from the response “2. Since Mr Tidey’s death, we have already implemented a standardised log across all of our Community Mental Health Recovery Service (CMHRS) teams, which must be used to record all of the 39/24 forms (now referred to as Single Combined Assessment of Risk Form (SCARF)) that are received by the CMHRS. The log must record the date the SCARF is received, the name to whom the SCARF relates and what action has been taken in response. I have received assurances that these logs are now being completed by the CMHRS teams.” Source location 2018-0140-Response-by-Surrey-Borders-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 a high-risk SCARF checking process requiring MASH practitioners to telephone relevant community mental health teams about receipt and urgent action.
Verbatim wording from the response “3. However, we have also devised a new checking system between the MASH and the CMHRS teams. In the future, when the Trust’s practitioner within the MASH receives a SCARF form which indicates a high risk to an individual and which the practitioner considers requires urgent action by the CMHRS team, a phone call will be made by the MASH practitioner to the relevant CMHRS to check that the SCARF has been received and to notify the CMHRS that action is required urgently.” Source location 2018-0140-Response-by-Surrey-Borders-NHS-Trust
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 A phone call for every SCARF form was not considered workable because of the volume of forms received and processed.
Verbatim wording from the response “We discussed whether a phone call could be made by the Trust’s MASH practitioner to the CMHRS every time a SCARF form is sent from the MASH to the CMHRS, however due to the volume of SCARF forms received and processed this was not considered to be a workable solution.” Source location 2018-0140-Response-by-Surrey-Borders-NHS-Trust
Open published response
14 Dec 2017 Ernest Wayne Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure of the correspondence-review system to identify GP requests for medication reviews View source Lack of a clear system for updating GPs about patient disengagement when the medical team is not involved in care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ernest Wayne Smith · 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
Ernest Wayne Smith was found deceased in woodland at Chelsham Common, Warlingham, on 13 June 2016. The inquest concluded that the medical cause of death was hanging and recorded a short-form conclusion of suicide. Concerns included failures to arrange or follow up medication reviews and the absence of a clear system for updating GPs about missed appointments and disengagement where the CMHRS medical team was not involved.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the correspondence-review system to identify GP requests for medication reviews
Wider context from the report “- The system for considering correspondence received from GPs, including requests for medication reviews, appears to remain the same as the system which was in place at the time of Mr Smith’s death and which failed to identify ████████ request for a medical review on 7 March 2016.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for updating GPs about patient disengagement when the medical team is not involved in care
Wider context from the report “- There are a number of CMHRS service users who, like Mr Smith, are not under the CMHRS medical team, but whose care is led by other members of the multi-disciplinary team, including clinical psychologists and care co-ordinators. The court heard that there is a clear system in place in the medical team for updating GPs on progress and also in the event of failures to attend appointments (DNAs). However, it did not appear to the court that there was a clear system for updating GPs when the medical team was not involved in a patient’s care . This risks GPs being unaware , as ████████ was in this inquest, of instances in which their patient begins to display signs of disengagement with the service .
” 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 Create an action plan addressing the concerns raised in the PFD report.
Verbatim wording from the response “The PFD report has been carefully considered and discussed by the Trust’s Adult Mental Health Division, within which the Community Mental Health Recovery Services are located. The Division has created the attached action plan, which outlines the actions that the Division is going to take in order to address your concerns. I hope the action plan is self explanatory.” Source location 2017-0459-Response-by-Surrey-NHS-Trust
Open published response
18 Apr 2017 Daniel Maher · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to routinely share clinical assessment records with receiving community mental health services outside the county View source Failure to provide timely access to patient information held by mental health services in other counties 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
Daniel Maher · 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 Maher was found hanging at his home on 26 May 2016, and efforts to resuscitate him were unsuccessful. The report raised concerns that significant information about vulnerable individuals may not be readily accessible when mental health services in West Sussex and Surrey are involved, including because of limited access to records and reliance on verbal referrals without routinely shared paperwork.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely share clinical assessment records with receiving community mental health services outside the county
Wider context from the report “During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP.
The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey.
- The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county. As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours.
- The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals . In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection .
- As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely access to patient information held by mental health services in other counties
Wider context from the report “During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP.
The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey.
- The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county . As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours .
- The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection.
- As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report
15 Feb 2016 Adam James Withers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to identify retrospective patient-record entries View source Lack of clear guidance on preserving original records after a patient’s death View source Insufficient recording of psychiatric patient observations and interactions View source Lack of prescribed safe nursing staffing levels for acute psychiatric wards 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
Adam James Withers · 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
Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify retrospective patient-record entries
Wider context from the report “It was clear from the evidence that any note made in a patient’s record should be made contemporaneously or, if made later, should be timed, dated and labelled as retrospective . This is necessary to ensure that all notes are accurate and reliable.
The evidence at the inquest revealed that at least one member of nursing staff made entries on Adam Withers’ manuscript observation record after he had died, without marking the entries as retrospective . When giving evidence, the member of staff in question did not appear to understand that he ought not to have done so.
If permitted to continue, this practice could result in current and future patients’ notes containing inaccurate and unreliable, and potentially misleading, information and this could have an adverse impact on their assessment, treatment and care and upon the protection of their lives.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on preserving original records after a patient’s death
Wider context from the report “At the inquest an issue arose as to when the manuscript observation record for Adam Withers for the 9th May 2014 was completed and I asked to see the original document. I was provided with a witness statement from the Trust’s Medical Records Manager indicating that, after Adam Withers’ death, the original record had been scanned in to his electronic records and then destroyed. The Trust considers that this is permitted by the NHS Code of Practice on Record Management. It is not clear to me whether that is a correct analysis of the Code or not. No clear guidance appears to exist .
Whilst I understand that paper records may now routinely be scanned in to a patient’s electronic record and then destroyed, my concern relates to that taking place after a patient has died and it is apparent that the death must be reported to the police and/or coroner. The destruction of any original document which is still in existence at the time of death could undermine the efficacy of the police investigation and/or the coroner’s investigation. In turn, this could adversely affect the coroner’s ability to establish the facts of how the deceased person came by his death and to report concerns for the prevention of future deaths.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of psychiatric patient observations and interactions
Wider context from the report “It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient’s condition are important for the purposes of diagnosis and they provide the information which is needed for a reliable assessment of the patient’s progress and current level of risk of harm or death. It was accepted in evidence that this is especially so in relation to any patient whose condition fluctuates.
It was clear from the evidence that the nursing staff involved in Adam Withers’ care failed to record sufficiently his presentation and their interactions with him . For example, on the day of his death Adam Withers was subject to four observations per hour but no entries were made on his RIO notes or elsewhere about his state of mind or presentation at these observation points and no record was made about the conversation a nurse conducted with him that afternoon .
Some of the nursing staff who gave evidence appeared to have little understanding of the need to make such written records and/or their importance .
If permitted to continue, the insufficient recording of observations and events could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribed safe nursing staffing levels for acute psychiatric wards
Wider context from the report “At the inquest the number of nursing staff (Registered Nurses and Health Care Assistants) on duty on Elgar Ward was considered. It was apparent from the evidence that the nursing staff levels could result in patients on the ward being insufficiently supervised at meal times and staff stated in evidence that they did not always have time to read patients’ notes as they should.
Further, Elgar Ward is an acute psychiatric ward with both detained and voluntary patients. It is foreseeable that reactive and unplanned interventions will be required at times and that the level of observation needed by each patient will fluctuate. The staffing levels on Elgar Ward were deemed sufficient for only a fixed number of patients to be subject to increased observation levels, and only one patient to be under constant observation, at any one time. I was informed that if more patients required increased or constant observation, additional staff would be needed but may not be readily available.
I have been told by the Trust that no nationally prescribed safe staffing levels are in place for an acute psychiatric ward (whether based on patient to staff ratios or otherwise) and that the Trust considers its staffing levels to be in accordance with such guidelines as do exist. The Mental Health Taskforce’s recently published report entitled “The Five Year Forward View For Mental Health” does not appear to address this issue.
It does seem that the absence of prescribed safe nursing staff levels for acute psychiatric wards could leave such wards unable to provide, throughout each shift, the level of patient supervision, observation and intervention needed . This could adversely affect the staff’s ability to protect their patients’ lives.
” 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 Review the Records Management Policy and establish standards for factual, accurate, evidence-based and timely record keeping.
Verbatim wording from the response “We have since reviewed our Records Management Policy which has a section outlining the ‘Standards for Record Keeping’. Under these standards there is clear expectation that:” Source location Adam-WITHERS-Response
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 electronic patient records in Acute Services to provide an auditable record-entry time trail.
Verbatim wording from the response “In an emergency where staff are unable to record the times we would expect them to highlight that the record/entry is retrospective, but should still follow a chronological format of proceedings. Our use of the electronic patient record system in our Acute Services now removes any doubt about record entry time as every entry now leaves a clear audit trail which can be reviewed as required. Quality is further maintained when we share learning from our record keeping audits which we undertake as part of our clinical audit program.” Source location Adam-WITHERS-Response
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 Revise the Observation Policy to require comprehensive risk assessments and documented observation decisions, risks and triggers.
Verbatim wording from the response “We have also revised our Observation Policy to include much clearer guidance on how, when and where people should record all clinical interventions. This includes a review of the assessment section of this policy, which clearly states that all people that use our inpatient services will have a comprehensive Risk Assessment. This will include” Source location Adam-WITHERS-Response
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 Implement purposeful engagement in adult inpatient services and require timely recording of staff interactions in clinical records.
Verbatim wording from the response “We acknowledge that our record keeping practice did not meet our desired and expected quality levels in this instance and we have learnt from these identified deficiencies. We have already instigated work to further improve the quality of our engagement with people using our adult inpatient services, by ensuring that all interactions are meaningful, using a process of purposeful engagement (a modified form of intentional rounding). The purposeful engagement process assists our staff in ensuring continuous assessment of individuals so timely interventions can be undertaken when necessary. As part of this process we expect all staff in these services to record interactions in the person’s clinical records in a timely way.” Source location Adam-WITHERS-Response
Open published response
20 May 2015 Mrs Wanda Stachurska · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Lack of staff awareness of relevant mental health policies View source Failure to provide training or guidance to staff interpreting during mental health assessments View source Use of non-healthcare professionals to interpret during mental health assessments View source Routine use of untrained staff as interpreters for mental health assessments View source Failure to undertake a serious incident review after a patient death shortly after discharge View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Wanda Stachurska · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Wanda Stachurska was found deceased on 18 November 2014 after being discharged from hospital the previous evening following a suicide attempt involving an overdose and attempted hanging. Concerns included the quality of the mental health risk assessment, including the use of an untrained security guard as an interpreter and the failure to communicate relevant information about the earlier attempted hanging. The report also raised concerns that neither Trust conducted a serious incident review after her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of relevant mental health policies
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital ;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training or guidance to staff interpreting during mental health assessments
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of non-healthcare professionals to interpret during mental health assessments
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments ;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Routine use of untrained staff as interpreters for mental health assessments
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence ;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a serious incident review after a patient death shortly after discharge
Wider context from the report “(2) Neither SASH nor SABP had considered that they should undertake a serious incident review into the case despite the death of a patient only a few hours after discharge .
(a) An opportunity to learn lessons from the above events has hence been delayed and potentially been lost;
(b) To decline to conduct a serious incident review because of a pre-determined opinion that there had been not been any omissions or shortcomings by the organisation might reflect a misunderstanding by SASH of the purpose and value of such investigations.
” 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 Require staff interpreters used in emergencies to be healthcare professionals aware of accountability, responsibility and confidentiality duties.
Verbatim wording from the response “1c) In SASH’s procedures it is outlined that a member of staff can be used as the interpreter in an emergency situation. However when using a member of staff as an interpreter, Psychiatric Liaison Services will ensure that this member of staff must be a healthcare professional and is aware of their accountability, responsibility and confidentiality duties.” Source location 2015-0199-Response-by-Surrey-and-Borders-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 Make the SASH translation-services policy mandatory reading for staff working at East Surrey Hospital.
Verbatim wording from the response “1a) We have worked with our colleagues at East Surrey Hospital to ensure that a shortcut to Surrey and Sussex Hospital (SASH) policies is loaded onto all of our Psychiatric Liaison staff’s computers to ensure ease of access for our staff. The SASH policy relating to using translation services has been made available as mandatory reading for our staff working at SASH.” Source location 2015-0199-Response-by-Surrey-and-Borders-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 Load a shortcut to SASH policies onto Psychiatric Liaison staff computers.
Verbatim wording from the response “1a) We have worked with our colleagues at East Surrey Hospital to ensure that a shortcut to Surrey and Sussex Hospital (SASH) policies is loaded onto all of our Psychiatric Liaison staff’s computers to ensure ease of access for our staff. The SASH policy relating to using translation services has been made available as mandatory reading for our staff working at SASH.” Source location 2015-0199-Response-by-Surrey-and-Borders-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 Contact provider organisations early and agree responsibility for reporting and serious-incident investigations.
Verbatim wording from the response “In this instance at the time of the incident coming to light, we believed that the lead provider in the care at the time of the death was going to report and lead the investigation process and as due process we would have taken part in the investigation. Unfortunately in this instance all the communication regarding the responsibility for the serious incident investigation was managed through the HM Coroner’s Office instead of directly with our acute care provider colleagues as per our general practice. We have taken steps to ensure that when such issues arise we as providers make contact with each other early and agree reporting and investigation responsibilities.” Source location 2015-0199-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
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 Responsibility for reporting and leading the serious incident investigation was assigned to the lead provider, while the Trust expected to participate.
Verbatim wording from the response “In this instance at the time of the incident coming to light, we believed that the lead provider in the care at the time of the death was going to report and lead the investigation process and as due process we would have taken part in the investigation. Unfortunately in this instance all the communication regarding the responsibility for the serious incident investigation was managed through the HM Coroner’s Office instead of directly with our acute care provider colleagues as per our general practice. We have taken steps to ensure that when such issues arise we as providers make contact with each other early and agree reporting and investigation responsibilities.” Source location 2015-0199-Response-by-Surrey-and-Borders-Partnership-NHS-Trust
Open published response
30 Jan 2015 Simon Richard Tree (Formerly Gary Charles Randall) · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to maintain effective monitoring of people leaving through the airlock View source Failure of the airlock system to prevent patients from tailgating authorised visitors 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
Simon Richard Tree (Formerly Gary Charles Randall) · 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
Simon Tree, a voluntary patient at the Abraham Cowley Unit and known suicide risk, left the unit unsupervised on 17 February 2012 and was found drowned in the River Thames on 18 February 2012. The principal concern was inadequate security and monitoring of the airlock system, which allowed patients to leave by tailgating visitors and created opportunities for unsupervised exit.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective monitoring of people leaving through the airlock
Wider context from the report “During the Course of the Inquest evidence came to light that whilst the door that Simon Tree left the unit from was now secure, there are security issues with the new airlock system. The Court heard that the onus of releasing people from the unit is placed on ward staff, who operate the airlock system remotely from the ward. Patients have been able to ‘tailgate’ visitors leaving legitimately and the Court heard 4 people had managed to leave this way in the last 12 months. On one occasion the camera in the airlock was simply moved to create a blind spot . A reception area exists beyond the airlock where at times there are staff present with a clear view of who is leaving. These staff appear to plays no roll in monitoring those who are leaving thru the airlock .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the airlock system to prevent patients from tailgating authorised visitors
Wider context from the report “During the Course of the Inquest evidence came to light that whilst the door that Simon Tree left the unit from was now secure, there are security issues with the new airlock system . The Court heard that the onus of releasing people from the unit is placed on ward staff, who operate the airlock system remotely from the ward. Patients have been able to ‘tailgate’ visitors leaving legitimately and the Court heard 4 people had managed to leave this way in the last 12 months . On one occasion the camera in the airlock was simply moved to create a blind spot. A reception area exists beyond the airlock where at times there are staff present with a clear view of who is leaving. These staff appear to plays no roll in monitoring those who are leaving thru the airlock.
” Open source report
28 Jan 2015 Katherine Liana Bonaventura · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to record the outcome of mental state assessments after inpatient leave View source Lack of a system for sufficiently thorough private consultation with family members or carers after inpatient leave View source Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave 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
Katherine Liana Bonaventura · 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
Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the outcome of mental state assessments after inpatient leave
Wider context from the report “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record. ”
It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area.
It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return.
It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded , at the time of arrival back on the Unit.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for sufficiently thorough private consultation with family members or carers after inpatient leave
Wider context from the report “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.”
It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient , (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area.
It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return.
It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible . One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so . It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted, and its outcome is recorded, at the time of arrival back on the Unit.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring sufficient mental state assessment of patients returning from inpatient leave
Wider context from the report “It was clear from the evidence that the Trust had and has in place Guidelines entitled “Working Age Adults Inpatient Leave of Absence Guidelines for Detained Patients” dated November 2011 and reviewed in July 2012. Those guidelines state, “Upon return from leave, an assessment of the patient should occur and the family member, carer should be consulted to ensure any issues arising during leave are noted. The outcome of this discussion should be documented in the patient’s clinical record.”
It was apparent from the evidence that (i) the consultation with the family member / carer may consist of no more than an exchange of a few words in the presence of the patient, (ii) it is sometimes difficult for a family member / carer to provide all relevant information to staff in those circumstances and (iii) if staff are not immediately aware of any issues arising, their “assessment of the patient” may consist of no more than an exchange of a few words in the reception area .
It is, therefore, of great importance that staff elicit as much information as possible about the leave and any concerns arising, at the point of the patient’s return.
It is of concern that there is no system in place to ensure that a sufficiently thorough consultation takes place with the family member / carer, which is designed to elicit as much information as possible as soon as possible. One nurse stated in evidence that it is now his personal habit to escort the family member / carer off the Unit so that he can conduct a further, private, consultation, but that not all nurses do so. It is also of concern that there is no system in place to ensure that a sufficient mental state assessment of the patient is conducted , and its outcome is recorded, at the time of arrival back on the Unit.
” Open source report
24 Nov 2014 William Philip Hafele · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Failure of communication between police and hospital staff about missing-person status View source Failure to make enquiries or investigations to ascertain a missing person’s whereabouts View source Failure of briefing training to accurately reflect the definition of absent View source Lack of adequate training for police and hospital staff on missing-person procedures, responsibilities and risk assessment View source Omission of critical information required for missing-or-absent risk assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Philip Hafele · 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
William Philip Hafele, who had a history of mental ill health and alcohol dependence, was admitted to hospital after being found intoxicated and wanting to take his own life. After leaving the ward and being redesignated by police from missing to absent, no immediate enquiries were made; he was later found dead in a hotel room after suffocating using helium gas. The principal concerns related to inadequate training, risk assessment, communication, and understanding of responsibilities between the police and hospital staff.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between police and hospital staff about missing-person status
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make enquiries or investigations to ascertain a missing person’s whereabouts
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of briefing training to accurately reflect the definition of absent
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate training for police and hospital staff on missing-person procedures, responsibilities and risk assessment
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions .
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of critical information required for missing-or-absent risk assessment
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit uploaded MISPER documentation for completeness.
Verbatim wording from the response “photo and description of general appearance. To ensure that relevant information is recorded and reported to the Police as part of the missing persons report, it is now expected practice for all staff to ensure that they upload this document onto our Electronic Patient System (RiO) in a timely manner. This will now be audited for completeness.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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 Emphasise and disseminate the MISPER process to ward staff and managers.
Verbatim wording from the response “We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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 ward managers to conduct quarterly audits of MISPER Appendices A and B and discuss emerging issues at the Acute Care Forum.
Verbatim wording from the response “The MISPER agreement has been widely discussed in teams and presented at our managers meetings on a number of occasions. In addition mandatory training has now been arranged for all staff within the unit to be completed by the end of February 2015. To further ensure embedding of the process, we will now require our ward managers to undertake a quarterly audit on MISPER forms Appendix A & B and any emerging issues are discussed at our Acute Care Forum meeting.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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 Arrange mandatory MISPER training for all unit staff, with completion required by the end of February 2015.
Verbatim wording from the response “The MISPER agreement has been widely discussed in teams and presented at our managers meetings on a number of occasions. In addition mandatory training has now been arranged for all staff within the unit to be completed by the end of February 2015. To further ensure embedding of the process, we will now require our ward managers to undertake a quarterly audit on MISPER forms Appendix A & B and any emerging issues are discussed at our Acute Care Forum meeting.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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 flow chart directing staff through enquiries after a person goes missing.
Verbatim wording from the response “A flow chart clearly outlining the process to make inquiries further to a missing persons report to the Police has been developed. It contains clear directions on the process that needs to be undertaken when someone has not returned to the ward. This standardisation of approach will support staff in making enquiries or investigations when a person using our services goes missing from the wards.” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
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 staff to complete and upload MISPER Appendix A information to RiO for missing-person reports.
Verbatim wording from the response “Staff have been further clearly instructed to complete Appendix A of the MISPER agreement. This outlines details such as name and location of the unit reporting the missing person, the risk assessment zoning and clear justification for the category, personal details of the person who may have gone missing with an option to attach a” Source location 2014-0511-Response-by-Surrey-Borders-Partnership-NHS
Open published response
27 Oct 2014 Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to retain complete primary source data within the Phoenix Programme View source Open and accessible ligature points within prisoner cells View source Failure to ensure multidisciplinary attendance or input at ACCT reviews View source Failure to record significant medical events in prisoner non-medical records accessible to discipline staff View source See 1 more concern
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
Chrylin Angela Maria Norrell-Goldsmith · 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
Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain complete primary source data within the Phoenix Programme
Wider context from the report “3. Retention of Primary Source Data within the Phoenix Programme
Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One record .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Open and accessible ligature points within prisoner cells
Wider context from the report “1. Open pipe work within the cell
Whilst it may not be possible to remove all potential ligature points within a cell, removal of easily accessible and obvious ligature points may serve to reduce the risk of self harm and suicide to vulnerable prisoners .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure multidisciplinary attendance or input at ACCT reviews
Wider context from the report “2. Multi-Disciplinary Attendance / Input at ACCT Reviews
Consideration should be given to ensuring that all staff, including prison staff, healthcare staff and In Reach staff understand the importance of requiring and providing multi-disciplinary attendance, or alternatively, multi-disciplinary input at all ACCT reviews .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant medical events in prisoner non-medical records accessible to discipline staff
Wider context from the report “4. Recording Significant Medical Events on a prisoner’s Non-medical Records
Consideration should be given to ensuring that all members of healthcare and In Reach staff working within a prison environment record all significant medical events that may impact upon a prisoner’s risk assessment for self-harm or suicide in a place or manner that is readily accessible to the discipline staff at the prison , in addition to any entry made in respect thereof in the System One record .
” Open source report
28 Jul 2014 Frances Claire ANDRADE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Lack of clear and unequivocal advice to vulnerable witnesses about obtaining psychiatric counselling related to forthcoming criminal evidence View source Failure to provide complainants with full and timely explanations of trial judge directions on indictment counts after no-case-to-answer submissions View source Failure to secure medication prescribed to one family member from access by another family member with a history of overdoses 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
Frances Claire ANDRADE · 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
Frances Claire Andrade died after taking an overdose of fluoxetine and insulin, following a period involving repeated overdoses and increasing distress around criminal proceedings. The report raised concerns about advice and support for vulnerable witnesses, explanations of trial directions, and securing medication prescribed to another family member after repeated overdoses.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and unequivocal advice to vulnerable witnesses about obtaining psychiatric counselling related to forthcoming criminal evidence
Wider context from the report “1. Consideration should be given to instituting measures that will ensure that clear and unequivocal advice is given to a vulnerable witness in relation to the obtaining of psychiatric counselling in relation to issues arising from evidence which they will be giving in forthcoming criminal proceedings.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complainants with full and timely explanations of trial judge directions on indictment counts after no-case-to-answer submissions
Wider context from the report “2. Consideration should be given to instituting measures that will ensure that complainants in criminal trials are given a full and timely explanation as to the directions given by a trial judge in relation to counts on an indictment following the receipt of submissions of there being no case to answer in respect of those counts.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure medication prescribed to one family member from access by another family member with a history of overdoses
Wider context from the report “3. Where there is a history of overdoses being taken by family member A using medication that is prescribed to family member B , consideration should be given to what steps could reasonably be taken to secure that medication with a view to restricting access to it by family member A .
” 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 Develop and use a local protocol for safe medication management, including safety plans with people and families where medication-overdose history is identified.
Verbatim wording from the response “We monitor compliance with care planning through our Board Key Performance Indicators to ensure that the process of care planning remains embedded. Our Home Treatment Team has developed a local protocol to ensure safety of medication management and further to the investigation they are expected to establish a safety plan with the person and family for the safe storage of medication if a history of overdosing on family’s medication has been revealed.” Source location 2014-0347-Response-by-Surrey-and-Borders-Partnership-NHS
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 comprehensive collaborative risk-management care plans for identified medication-hoarding or overdose risks and share them with the involved care team.
Verbatim wording from the response “Further to our own internal investigation we have since recommended that staff should ensure that when specific risks are identified in a person [e.g. a person is assessed to be hoarding medication and using other person’s prescribed medication to overdose], this must be followed by comprehensive risk management care plan/s in collaboration with the person/s and shared with the Team directly involved in the person’s care. We believe that a process managed through effective care planning arrangements with clear engagement with the person using our service and the carer, would be the most effective process that may go some way to mitigate this risk.” Source location 2014-0347-Response-by-Surrey-and-Borders-Partnership-NHS
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 Limited influence over how the public stores medication makes it unrealistic to fully mitigate overdose risk through medication security.
Verbatim wording from the response “Due to the limited influence we have on how members of the public store or manage their medication it will, unfortunately, be unrealistic for us to say we can fully mitigate against this risk going forward. We have however taken steps to ensure that our staff interactions with family carers and people using services recognise this risk and highlight it as an area to be considered by all parties involved.” Source location 2014-0347-Response-by-Surrey-and-Borders-Partnership-NHS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations