Concerns raised 7 Delays in contacting 999 and the on-call doctor during cardiac arrests View source Inability of staff to perform CPR properly View source Failure to coordinate cardiac-arrest responses View source Failure to make an adequate 999 call during cardiac arrests View source Lack of Naloxone training for staff View source Failure of nursing staff to know leave conditions View source Failure to properly monitor leave conditions View source See 4 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
Kristian Edward Allen · 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
Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in contacting 999 and the on-call doctor during cardiac arrests
Wider context from the report “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability of staff to perform CPR properly
Wider context from the report “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly , the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate cardiac-arrest responses
Wider context from the report “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised . Nobody appeared to be in charge , staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make an adequate 999 call during cardiac arrests
Wider context from the report “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard , there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Naloxone training for staff
Wider context from the report “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training . I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to know leave conditions
Wider context from the report “I am concerned that s17 leave is being authorised by staff in ignorance of the leave conditions . In this particular case, the responsible clinician granted leave on the 13th of February 2025, a condition being that Kristian had to test negative for drug use before leave was allowed. On the 15th of February 2025, the nurse in charge granted escorted leave despite Kristian having tested positive for cocaine use. He was unaware of the restrictions on Kristian’s leave. Evidence was heard during the Inquest that this was a frequent problem and I am concerned that nursing staff are unaware of leave conditions and this is not being properly monitored. This runs a risk of future fatalities if leave is being granted inappropriately.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly monitor leave conditions
Wider context from the report “I am concerned that s17 leave is being authorised by staff in ignorance of the leave conditions. In this particular case, the responsible clinician granted leave on the 13th of February 2025, a condition being that Kristian had to test negative for drug use before leave was allowed. On the 15th of February 2025, the nurse in charge granted escorted leave despite Kristian having tested positive for cocaine use. He was unaware of the restrictions on Kristian’s leave. Evidence was heard during the Inquest that this was a frequent problem and I am concerned that nursing staff are unaware of leave conditions and this is not being properly monitored . This runs a risk of future fatalities if leave is being granted inappropriately.
” Open source report
Concerns raised 11 Failure of nurses to read notes before significant decisions View source Lack of training for nurses moving from different settings to the Haven View source Lack of family involvement in risk management and planning View source Unavailability of case-note alerts for restrictions on trips out View source Insufficient policy focus on trips out View source Lack of auditing of trip-out observations against case notes and authorisation View source Insufficient formal control of trips out View source Lack of a written checklist for authorising trips out View source Variation in the timing of notes View source Failure to complete records of decisions taken View source Uncertainty about when formal safety plans or care plans should be completed View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amy Clare CHAPMAN · 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
Amy Clare Chapman, who was experiencing a mental health crisis and assessed as at high risk of suicide, was admitted to the Haven Unit at Millview Hospital on 23 March 2025. On 27 March, she was permitted to leave the unit twice without adequate checking of her records, family contact, or documentation, and later jumped from a bridge, dying from her injuries. The principal concerns included insufficient risk assessment and planning for trips out, failures to read and record notes, inadequate family involvement, uncertainty over care and safety plans, and gaps in training, alerts, checklists, and auditing.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nurses to read notes before significant decisions
Wider context from the report “3. Nurses not reading notes before taking significant decisions is a very serious concern, as is not then completing records of the decisions taken.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for nurses moving from different settings to the Haven
Wider context from the report “7. There seems to be a lack of training for nurses moving from different settings to the Haven .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of family involvement in risk management and planning
Wider context from the report “6. The lack of family involvement in risk management and planning is a breach of policy, and would have been straightforward in this case.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of case-note alerts for restrictions on trips out
Wider context from the report “8. I am concerned as to whether there is now a facility in the case notes (now SystmOne) for there to be alerts around restrictions on trips out .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient policy focus on trips out
Wider context from the report “2. This may have been informed by there being insufficient focus in the policy , including in the policy as amended in October 2025.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of trip-out observations against case notes and authorisation
Wider context from the report “10. There has been a commitment to look at this too, but whilst care plans are the subject of audits, there is no auditing of the observations document against case notes , checking that trips out were properly risk assessed and authorised .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient formal control of trips out
Wider context from the report “1. Insufficient focus at the Brighton Haven on whether and how trips out should take place . I am concerned, bearing in mind evidence on record-checking and keeping, that too much informality has crept in .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written checklist for authorising trips out
Wider context from the report “9. There has been a commitment to look again at this, but there is currently no written checklist for nurses to use when authorising trips out .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Variation in the timing of notes
Wider context from the report “4. I am concerned about the variation in practice on the timing of notes .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete records of decisions taken
Wider context from the report “3. Nurses not reading notes before taking significant decisions is a very serious concern, as is not then completing records of the decisions taken .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about when formal safety plans or care plans should be completed
Wider context from the report “5. I am concerned about what seems to be a lack of certainty concerning when formal safety plans (and/or care plans) should be completed . An informal one on admission followed by a full one after 24 hours seems reasonable, but the process and expectations ought to be clarified.
” 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 a specific standard requiring consistent recording of intervention timings at Brighton Haven.
Verbatim wording from the response “Regarding the variation in practice on the timing of notes, the Trust has recognised that there was no specific standard in place at the Brighton Haven, so action has been taken to develop a specific standard to ensure accurate timings of interventions are consistently recorded.” Source location Response from Sussex Partnership 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 Review and strengthen the Haven induction process and maintain consistent staff supervision.
Verbatim wording from the response “Action has also been taken to review and ensure the Haven induction process is robust and that Supervision of staff is consistently in place to address any support needs of new staff.” Source location Response from Sussex Partnership 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 Update the Haven Operational Policy to clarify care-plan timing and require recorded care planning from admission.
Verbatim wording from the response “Action has also been taken to ensure there is certainty about when a formal care and safety plan should be completed. The Haven Operational Policy has been updated (to be ratified imminently) to include the following specificity:” Source location Response from Sussex Partnership 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 Record of Time Away and Return procedure and form to document leave plans, risk assessment, clinical decisions, and return concerns.
Verbatim wording from the response “The Brighton Haven has taken the action, agreed at the Inquest, to introduce a new procedure for staff to follow when risk assessing patients prior to them taking time off the Haven.
The new procedure has introduced an adaptation of the in-patient form, provided at Inquest, so that it is appropriate for use at the Haven. The new Haven 'Record of Time Away and Return' form is now completed by Haven staff as part of a focused, proactive, therapeutic conversation about the patient's time away from the Haven.
As the Haven is a voluntary, community service, patients are not detained at the Haven and do not require permission to leave. Yet, the Trust wholly recognises that, in the interests of patient safety, it is essential to be vigilant about a patient's plans and whereabouts when away from the Haven, and careful, structured, collaborative consideration is needed.” Source location Response from Sussex Partnership 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 Monitor the implemented actions through ongoing focused auditing and take further improvement action when required.
Verbatim wording from the response “The new Haven 'Record of Time Away and Return' form is now part of the Haven's clinical records audit programme, to ensure it is being correctly used and that staff can be further supported and trained in the new process, if needed.” Source location Response from Sussex Partnership 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 Deliver Triangle of Care training and carer-involvement simulation sessions for Brighton Haven staff.
Verbatim wording from the response “A number of actions have also been taken to improve family involvement, including, as part of a specific Brighton Haven Team training day, reaffirming the principles of the Triangle of Care and conducting carer involvement simulation sessions to improve practice. Triangle of Care is a nationally recognised, collaborative framework that involves the patient, their carer, and professionals working together to support recovery, safety, and wellbeing. Adherence to the framework will be monitored.” Source location Response from Sussex Partnership Foundation Trust
Open published response
Concerns raised 1 Lack of information being made available to the GP to prevent duplicitous prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Kagure Pauline REECE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Kagure Pauline Reece died on 7 March 2023 after being found hanging at her home address. The principal concern was that inadequate information-sharing between mental health services and the GP could result in patients receiving no medication or excessive medication due to duplicitous prescribing.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of information being made available to the GP to prevent duplicitous prescribing
Wider context from the report “The MATTERS OF CONCERN are that in the absence of information being made available to the GP there is a risk that patients will not receive any medication or receive excessive amounts of medication due to the risk of duplicitous prescribing .
” 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 Migrate to the SystmOne electronic patient record system.
Verbatim wording from the response “I am able to confirm that after a lengthy consultation, procurement and enablement process, in November 2025 the Trust will be migrating to a new Electronic Patient Record system, namely SystmOne. This system is widely used by many other NHS providers, including GPs and has the potential for incorporated prescribing functions. After November, the Trust will therefore be able to integrate with GP surgery systems and facilitate two-way and real time sharing of information which should alleviate this risk considerably.” Source location Response from Sussex 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 Enable two-way, real-time information sharing with GP practices and provide sharing agreements.
Verbatim wording from the response “I am able to confirm that after a lengthy consultation, procurement and enablement process, in November 2025 the Trust will be migrating to a new Electronic Patient Record system, namely SystmOne. This system is widely used by many other NHS providers, including GPs and has the potential for incorporated prescribing functions. After November, the Trust will therefore be able to integrate with GP surgery systems and facilitate two-way and real time sharing of information which should alleviate this risk considerably.” Source location Response from Sussex 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 Establish electronic prescribing, prioritising community electronic prescribing within the programme.
Verbatim wording from the response “In addition, as a part of our broader IT developments we are also working to establish electronic prescribing which will further enhance the safety of prescribing practices. This is a more complex part of the programme and the time frame for a complete roll out is not clear at this stage, however it remains a priority for us. Given the risk concerns you have identified,” Source location Response from Sussex Partnership NHS
Open published response
Concerns raised 4 Failure to provide young people and their families with information about available suicide prevention services View source Reduction of services for people with mental health difficulties due to cutbacks and funding issues View source Failure of suicide prevention contact services to accommodate people with hearing difficulties or other disabilities View source Failure of suicide prevention contact numbers to provide continuous access to someone able to speak with callers 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
Harry Benjamin SOUTHERN · 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
Harry Southern had a history of mental illness, previous suicide attempt and traumatic events in the final year of his life. He died after tying a ligature around his neck with the intention of ending his life. The report raised concerns that young people and their families may not receive accessible, reliable information or timely contact with mental health and suicide-prevention services, and that funding reductions could further reduce available support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide young people and their families with information about available suicide prevention services
Wider context from the report “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal.
However, I am concerned that this information is not in fact provided to people in Harry’s circumstances . Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal . Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers.
I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem.
The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them ) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reduction of services for people with mental health difficulties due to cutbacks and funding issues
Wider context from the report “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal.
However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers.
I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further . The Health Secretary will be copied into this Report because I am concerned this may well be a national problem.
The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of suicide prevention contact services to accommodate people with hearing difficulties or other disabilities
Wider context from the report “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal.
However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities . Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers.
I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem.
The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of suicide prevention contact numbers to provide continuous access to someone able to speak with callers
Wider context from the report “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal.
However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers.
I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem.
The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this.
” 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 Promote online mental-health signposting information through NHS, primary-care, local-authority and voluntary-sector partners.
Verbatim wording from the response “I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust” Source location Response from Sussex Partnership 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 Raise the gap between helpline demand and available financial resources with NHS Sussex commissioners.
Verbatim wording from the response “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.” Source location Response from Sussex Partnership 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 Improve Sussex Mental Health Line productivity to address demand and unanswered calls.
Verbatim wording from the response “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.” Source location Response from Sussex Partnership 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 Promote the 24/7 Text SUSSEX to 85258 mental-health support service through the Trust and partner organisations.
Verbatim wording from the response “An additional service which is now regularly promoted by both the Trust and partner organisations, including campaigns which are targeted specifically at students, is 'Text SUSSEX to 85258'. It is a digital means for people to access help with their mental health. The service, which is delivered through the national text messaging service Shout, is free and is available 24 hours a day, seven days a week.” Source location Response from Sussex Partnership 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 Make ongoing Sussex Mental Health Line improvement a key objective in the 2025/26 annual plan.
Verbatim wording from the response “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.” Source location Response from Sussex Partnership 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 Change Sussex Mental Health Line working patterns to improve call accessibility.
Verbatim wording from the response “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.” Source location Response from Sussex Partnership 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 Recruit staff to improve Sussex Mental Health Line capacity.
Verbatim wording from the response “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.” Source location Response from Sussex Partnership 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 Transform Staying Well into an open-access out-of-hours crisis service, rebrand and promote it, and increase its availability.
Verbatim wording from the response “Over the last 18 months, the Staying Well service, which you heard some detail about during Harry's Inquest, has also been transformed into an open access service to provide support to people who are experiencing a self-defined mental health crisis, as an alternative to attending A&E. It is an out-of-hours crisis support service which is co-delivered by voluntary, community and social enterprise (VCSE) providers and the Trust has worked with those VCSE partners to rebrand and promote Staying Well, and increase the hours it is available, resulting in a substantial increase in the number of people attending in person.” Source location Response from Sussex Partnership 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 and launch consistent online mental-health signposting information, categorised by how people may be feeling.
Verbatim wording from the response “I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust” Source location Response from Sussex Partnership 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 Launch multi-agency Neighbourhood Mental Health teams to coordinate access to NHS and voluntary-sector support.
Verbatim wording from the response “In relation to alternative support, I am pleased to say that the Trust has now launched the New Neighbourhood Mental Health teams that you also heard about during the Inquest. As they are multi-agency teams they enable improved access to the breadth of services, be that NHS or voluntary sector services, to provide the best and most accessible support for those experiencing mental ill-health. I know that the importance of working collaboratively was heard throughout Harry's Inquest as he was also receiving support from his GP, a private counsellor and had third sector input too. The new Neighbourhood teams support a co-ordinated approach to ensure all system agency partners are aware of exactly what is available across, what is recognised as being a complex mix of primary and secondary healthcare as well as vital voluntary sectors.” Source location Response from Sussex Partnership 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 A range of accessible community and crisis options, rather than improved helplines alone, is considered sufficient to provide local support 24/7.
Verbatim wording from the response “All the aforementioned collaborative, partner working is part of the national strategy to improve community and crisis services to deliver more mental health crisis care in the community, close to people’s homes, through new models of care and support which is key to the long-term sustainability of the NHS. The aim being to improve accessibility of mental health support, not by focusing on improving helplines etc, but by having a range of accessible options which, collectively provide access to local support 24 hours a day, 7 days a week.” Source location Response from Sussex Partnership Foundation Trust
Open published response
Concerns raised 2 Lack of policy or guidance for assessing risks posed by supplied fixtures and fittings View source Availability of fixtures and fittings that patients with acute mental health conditions may use to take their own life 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
Morgan Rose Betchley · 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
Morgan Rose Betchley had a history of mental health difficulties, self-harm and attempts to take her life, and was receiving inpatient care before she died after hanging herself in hospital grounds while awaiting a discharge meeting. The report identified a lack of policy or guidance for assessing risks posed by hospital fixtures and fittings. The inquest also described failures concerning admission, diagnosis, risk management, record keeping, family involvement, discharge planning, staff conduct and the quality of observations and interactions.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance for assessing risks posed by supplied fixtures and fittings
Wider context from the report “There is no policy or guidance to staff for the assessment of risk posed by fixtures and fittings supplied by the Trust (in this particular case it was the Sussex Partnership Foundation Trust).
There is therefore the risk that fixtures and fittings supplied and/or not removed by the Trust from patients, who are suffering from acute mental health, are at risk of utilising these items to take their own life.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Availability of fixtures and fittings that patients with acute mental health conditions may use to take their own life
Wider context from the report “There is no policy or guidance to staff for the assessment of risk posed by fixtures and fittings supplied by the Trust (in this particular case it was the Sussex Partnership Foundation Trust).
There is therefore the risk that fixtures and fittings supplied and/or not removed by the Trust from patients, who are suffering from acute mental health, are at risk of utilising these items to take their own life .
” Open source report
Concerns raised 6 Ineffective and insufficiently repeated mental health training for police officers View source Failure to share all relevant information with mental health practitioners in a timely manner View source Lack of joint training between police and mental health services on information sharing View source Lack of defined information-sharing arrangements for the Rapid Response Service View source Failure to ensure police officers understand mental health issues and referral information requirements View source Lack of mandatory mental health training for existing officers and rollout of accredited training for new officers 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
Ryan Louis Ouslem · 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 Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective and insufficiently repeated mental health training for police officers
Wider context from the report “Sussex police were afforded the opportunity to provide information about their training provision after the inquest. I have considered this information and I still have concerns. The police have stated that mental health training has been a particular focus for some time. Despite this an officer with a training role was unable to explain what training that was and when they had received it.
It appears to me from the police response that whilst mental health training and resources are offered to existing officers it is still not mandatory. I note that new officers joining will be undergoing accredited mental health training but this has not yet been rolled out.
Whatever training and resources have been provided I remain concerned it has not been effective and is not repeated as often as may be required to provide officers with the necessary skills and knowledge .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share all relevant information with mental health practitioners in a timely manner
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner .
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint training between police and mental health services on information sharing
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned . I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined information-sharing arrangements for the Rapid Response Service
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out . Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police officers understand mental health issues and referral information requirements
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide .
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory mental health training for existing officers and rollout of accredited training for new officers
Wider context from the report “Sussex police were afforded the opportunity to provide information about their training provision after the inquest. I have considered this information and I still have concerns. The police have stated that mental health training has been a particular focus for some time. Despite this an officer with a training role was unable to explain what training that was and when they had received it.
It appears to me from the police response that whilst mental health training and resources are offered to existing officers it is still not mandatory . I note that new officers joining will be undergoing accredited mental health training but this has not yet been rolled out .
Whatever training and resources have been provided I remain concerned it has not been effective and is not repeated as often as may be required to provide officers with the necessary skills and knowledge.
” 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 monitoring information sharing between the Trust and Sussex Police through the Rapid Response Service.
Verbatim wording from the response “Prior to the launch of the RRS, representatives from the Trust met with Sussex Police's Mental Health Lead and a representative from West Sussex Fire and Rescue Service on 16 July 2024 which enabled a discussion of how it was anticipated the RRS would function when launched on 4 November 2024. One of the conclusions from the meeting was that there is scope for improvement of the flow of information between the police and mental health services and I address below the action the Trust has taken (and will continue to monitor) to make these improvements.” Source location Response from Sussex 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 Operate the newly implemented Rapid Response Service through a single point of contact to support consistent guidance and information sharing with police.
Verbatim wording from the response “The soft launch of the RRS went live on 4 November 2024.” Source location Response from Sussex 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 Continue discussions with Sussex Police about providing cross-training on mental health-related matters.
Verbatim wording from the response “Joint Training
The trust is not commissioned to provide training to Sussex Police and they employ their own Mental Health specialist. However I wish to assure you that this is not a bar to the Trust providing support to Sussex Police with mental health related training. I am able to advise you that immediately following the inquest, the Trust contacted Sussex Police to open the door to discussions about how we may approach cross training and these discussions are ongoing.” Source location Response from Sussex 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 Develop a trust-wide Standard Operational Procedure covering partner contact arrangements, risk management, documentation, information sources and evidence-based decisions.
Verbatim wording from the response “A trust wide Standard Operational Procedure for the RRS is being developed which will provide guidance to staff working within the RRS. This will embed the expectations placed” Source location Response from Sussex 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 The Trust is not commissioned to provide training to Sussex Police, which employs its own mental health specialist.
Verbatim wording from the response “Joint Training
The trust is not commissioned to provide training to Sussex Police and they employ their own Mental Health specialist. However I wish to assure you that this is not a bar to the Trust providing support to Sussex Police with mental health related training. I am able to advise you that immediately following the inquest, the Trust contacted Sussex Police to open the door to discussions about how we may approach cross training and these discussions are ongoing.” Source location Response from Sussex Partnership NHS Trust
Open published response
Concerns raised 10 Inadequate communication between the ward and family View source Failure to update the family responsibilities section of the care and safety plan View source Failure to provide the family with the Section 17 leave form View source Lack of an overnight care plan View source Inadequate communication within the ward View source Lack of a clear pathway for sharing private psychiatrist consultation and treatment details with NHS inpatient settings View source Failure to complete the daily care log View source Lack of senior officer knowledge of leave and clinical risk management policies View source Failure to record completion of a pre-leave risk assessment View source Failure to communicate self-harm risk and risk-minimisation strategies to the family 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
Caroline Victoria Forte · 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
Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the ward and family
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update the family responsibilities section of the care and safety plan
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the family with the Section 17 leave form
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an overnight care plan
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication within the ward
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for sharing private psychiatrist consultation and treatment details with NHS inpatient settings
Wider context from the report “Ms Forte had for a number of years been seeing a private psychiatrist. Details of her consultations and treatments were not made readily available to those working in the NHS Trusts. It appears that there is no clear pathway for details of any private psychiatrist consultations to be shared with those in either the acute or mental health inpatient settings. The concerns are that any relevant history may be lost and details of any regular medication being prescribed may not, in a time of crisis, be immediately known.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the daily care log
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of senior officer knowledge of leave and clinical risk management policies
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record completion of a pre-leave risk assessment
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate self-harm risk and risk-minimisation strategies to the family
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” 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 Update the Section 17 leave policy to incorporate the new form and other specified modifications.
Verbatim wording from the response “The s.17 leave policy is being updated, so that it incorporates the new form, as well as some other modifications. Once ratified, there will be corresponding training which is delivered by the Trust's Mental Health Act team which is overseen by the Trust's Legal Director. Regarding the ward's understanding of the Safe and Effective Assessment & Management of Clinical risk: Risk Management policy, I understand that this specifically centred on the aforementioned assessment of risk prior to s.17 leave and corresponding sharing of information within the ward and with the family.” Source location Response from Sussex Partnership 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 the new Record of Patient Leaving Ward document’s effectiveness after three months and report findings to the Acute Care Forum.
Verbatim wording from the response “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.” Source location Response from Sussex Partnership 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 Conduct a Trust-wide qualitative audit of inpatient records to assess care-plan completion and meaningful family or carer engagement, then present and monitor findings through the Effectiveness Committee.
Verbatim wording from the response “As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-” Source location Response from Sussex Partnership 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 Consider employing a Carers Lead to provide a primary point of contact for family members.
Verbatim wording from the response “reviews, or been contacted after, to be given an update. The ward's aim is to invite a relevant family member to their loved ones' MDT review meetings, so the family member can participate in the review and have an opportunity to give their own views. If they have not been able to attend then a call to the relevant family member is made after the meeting to ensure they are aware of the plan. Additionally, the ward is considering employing a "Carers Lead", who would provide a primary point of contact for all family members. Further, the aforementioned trust-wide care plan and risk assessment auditing includes qualitatively auditing to ensure meaningful, appropriate family/carer engagement, as part of the Trust's ongoing 2023/4 improvement plan.” Source location Response from Sussex Partnership 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 Monitor the quality of concise, precise information handovers between shifts and to multidisciplinary teams during daily handovers.
Verbatim wording from the response “The Amberley ward Matron led the ward's discussions about the improvements needed following the Inquest which, in addition to those already mentioned, has involved on-going monitoring of the quality of concise and precise handover of information (both verbal and written) from shift to shift, and to MDT, during MDT daily handovers. Additionally, the Matron has been working with the Trust's lead trainer for clinical risk and the Trust's suicide prevention lead, to fully understand early indicators of risk to ensure his ward is capturing and fully understanding these warning signs. The Matron has also been actively involved in the formulation of the new 'Record of patient leaving ward' document which Amberley ward will be using from the trust-wide implementation date of 1 July.” Source location Response from Sussex Partnership 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 Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.
Verbatim wording from the response “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.” Source location Response from Sussex Partnership 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 Audit monthly whether families participate in ward reviews or receive follow-up contact about the care plan when unable to attend.
Verbatim wording from the response “As indicated above, safety planning ought to be a collaborative process and I was truly saddened to hear that Caroline's family were left without strategies to support them to minimise Caroline's risks. Amberley ward have, of course, reflected, at length, on the sequence of events that led to Caroline's death. The Matron is overseeing monthly audits to check that family have either participated in ward” Source location Response from Sussex Partnership 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 Conduct monthly spot checks on Amberley ward to confirm overnight care plans are completed and uploaded for patients taking overnight leave.
Verbatim wording from the response “As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-” Source location Response from Sussex Partnership Foundation Trust
Open published response
28 Jan 2022 Jack Stephen TAYLOR · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 9 Mismatch between AWOL and missing-person risk assessment grading criteria View source Unavailability of patient transport for absconding-patient returns View source Inadequate monitoring and progression of missing-person investigations View source Failure to discuss and confirm AWOL risk grading with police call-takers View source Failure to require early provision of current risk assessments and completed AWOL forms View source Failure to trigger specialist-officer interventions for vulnerable or high risk missing persons View source Insufficient appropriately trained staffing to secure the return of absconding PICU patients View source Reliance solely on police assistance to secure the return of absconding PICU patients View source Failure to consider the full range of powers to secure the return of absconding PICU patients View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack Stephen TAYLOR · 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
Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Mismatch between AWOL and missing-person risk assessment grading criteria
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing .
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of patient transport for absconding-patient returns
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances .
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and progression of missing-person investigations
Wider context from the report “3. Sussex Police’s use of their Missing Persons Policy
I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details.
In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team.
I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention .
I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss and confirm AWOL risk grading with police call-takers
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing.
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require early provision of current risk assessments and completed AWOL forms
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing.
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger specialist-officer interventions for vulnerable or high risk missing persons
Wider context from the report “3. Sussex Police’s use of their Missing Persons Policy
I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details.
In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team.
I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention.
I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient appropriately trained staffing to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members . This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance solely on police assistance to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the full range of powers to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” 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 Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.
Verbatim wording from the response “Developing a Missing Persons Template (including an action plan)” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-develop a joint missing persons action plan defining proportionate actions and tasks for finding missing patients.
Verbatim wording from the response “Additionally, to improve information flow and the overall response to missing persons, it was agreed that work would commence on co-developing a joint missing persons action plan so both agencies can agree actions and tasks in relation to finding a missing person proportionate to the presenting risks.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.
Verbatim wording from the response “Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an escalation process clarifying site-wide colleague support when additional resources are needed for patient return.
Verbatim wording from the response “In addition, an improved escalation process has been implemented and added to the AWOL Policy so that SPFT staff are clear about site-wide support available from colleagues when additional resource is required to facilitate a patient's return.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve vehicle access and availability arrangements so staff can return patients when police involvement is unnecessary.
Verbatim wording from the response “SPFT recognises that police involvement in the return of a patient may be or may become unnecessary and, at times, a patient's return by SPFT staff, rather than the police, can be preferable to some patients. Alternatively, there will be cases where risk is such that the police must be involved in the return, hence the importance of robust risk assessments, clear communication and a dynamic joint action plan.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
15 Jul 2021 Henry James Holcombe · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2 Failure to require staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping observations View source Failure to produce effective action following Serious Incident reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry James Holcombe · 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
Henry James Holcombe’s death was investigated, and the inquest concluded that he died from natural causes. The report raised concerns about the ongoing failure to comply with therapeutic engagement and observation policies, including observations of patients described as asleep who were later found to have been dead for several 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping observations
Wider context from the report “(1) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 – page 5). Since 27.12.2019 to 5.3.2021 there have been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce effective action following Serious Incident reports
Wider context from the report “(1) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 – page 5). Since 27.12.2019 to 5.3.2021 there have been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced.
” 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 Strengthen internal monitoring of Policy compliance through weekly Ward Manager and monthly Matron reviews.
Verbatim wording from the response “Specifically, in response to the findings of our investigation into Mr Holcombe's death, we have strengthened our internal monitoring arrangements to ensure the” Source location 2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a quality-improvement programme addressing observation competencies, individualised care, patient experience, and night-time observations including seclusion and physical observations.
Verbatim wording from the response “Also, although Ms Hamilton-Deeley's concerns related particularly to safety at night, we have recognised that a systemic quality improvement approach is needed to ensure that therapeutic observations are of an appropriate standard. As a result, we are undertaking a robust programme of therapeutic observation Quality Improvement ('QI') work. The aim of this work is to improve the quality of therapeutic observations in terms of safety, effectiveness and experience; specifically, to ensure observations are therapeutic, individualised and skilled intervention that is responsive to a patient's needs, are least restrictive, and aimed at recovery. This QI work will give specific attention to:” Source location 2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance therapeutic-observation training and competency assessment, including for agency and bank staff.
Verbatim wording from the response “The Trust's actions, to date, in relation to this issue, have focused on staff training, competency and understanding of our Policy. This stipulates that: ‘If a member of staff is not able to observe the patient move or breath they must ensure the patient is conscious which will require entering the bedroom’ and staff competency and understanding of the Policy is assessed through competency checks. However, it is clear that further, sustained action is required to ensure that this requirement is fully understood and adhered to by all clinical staff.” Source location 2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider technological aids to support patient safety and enhanced physical observation, including remote monitoring of respiration, movement and heart rate.
Verbatim wording from the response “Additionally, consideration is being given to the potential use of technological aids to support patient safety and enhanced physical observation, which includes an electronic system to remotely monitor a patient’s respiration, movement and heart rate and flags immediate changes to the patient’s physical presentation.” Source location 2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Open published response
28 Jun 2021 Nicholas Jonathan SPOONER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Denial of mental health support for people in crisis with co-occurring substance abuse 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
Nicholas Jonathan SPOONER · 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
Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Denial of mental health support for people in crisis with co-occurring substance abuse
Wider context from the report “Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support .
” Open source report
21 Jun 2021 Rodney John DIXON · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Sub-optimal training for patient risk management View source Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments View source Sub-optimal training for Mental Health Act assessments View source Sub-optimal training for Mental Health Act assessors 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
Rodney John DIXON · 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
Rodney John Dixon took his own life at home in Eastbourne on 15 July 2019 during the course of a Mental Health Act Assessment, following deterioration in his mental and physical health. The report raised concerns that training on Mental Health Act assessments, patient risk management and assessors was sub-optimal, and that independent clinicians needed reasonable access to patient data before assessments.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal training for patient risk management
Wider context from the report “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists.
The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments
Wider context from the report “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists.
The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal training for Mental Health Act assessments
Wider context from the report “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists.
The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal training for Mental Health Act assessors
Wider context from the report “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists.
The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments.
” 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 Identify difficulties in established processes for accessing and sharing relevant patient information with MHA Assessors.
Verbatim wording from the response “The Crisis Resolution Home Treatment Team are the Trust team that are available to support the MHA Assessors with access to relevant patient information and are available 24 hrs a day. However, I recognise your concerns and, therefore, have asked the Deputy Chief Nurse, when she discusses matters with ESCC, to identify if there are any difficulties with these established access processes that need to be addressed.” Source location Response from Sussex 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 Established electronic, verbal and hard-copy information-sharing routes, supported by a 24-hour crisis team, provide access to relevant patient information.
Verbatim wording from the response “Regarding accessibility of relevant patient clinical information, I would like to assure you that it has long been the case that ESCC have had access to the Trust’s electronic record system, Carenotes, to enable patient information to be accessible to them. The expectation is that the ESCC AMHP would access the necessary information and appropriately share it with any independent s.12 doctor who does not have access. In addition, it has been the working practice for many years that the Trust also shares information verbally and/or by providing hard copies of relevant patient records to AMHPs and to independent s.12 doctors, as needed. This further communication route facilitates the sharing of information if, for any reason, electronic access to Carenotes is not achievable.” Source location Response from Sussex Partnership NHS Foundation Trust
Open published response
5 May 2021 Hannah Bampfylde · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Unclear responsibility for re-booking appointments after non-attendance View source Failure to ensure re-booking of appointments after non-attendance for newly referred patients View source Failure to routinely notify GPs of non-attendance with HATS View source Lack of a clear escalation pathway for non-attendance by newly referred patients 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
Hannah Bampfylde · 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
Hannah Bampfylde was found hanging in the garage of her mother’s home, where she had been staying, and the inquest determined that she took her own life. She had been referred to HATS for mental health input after an overdose, but missed or could not attend assessment appointments and was discharged without being assessed. The report identified unclear responsibility for rebooking missed appointments and a lack of routine notification to GPs when newly referred patients did not engage with the service.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for re-booking appointments after non-attendance
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA , or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure re-booking of appointments after non-attendance for newly referred patients
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely notify GPs of non-attendance with HATS
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP , although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS , meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear escalation pathway for non-attendance by newly referred patients
Wider context from the report “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services.
Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work.
No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement.
Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this.
The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place.
HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service.
The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator.
The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place.
- Appointments are not automatically re-booked when a person has failed to attend an appointment.
- It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors).
- GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.
Consideration should be given to whether any steps can be taken to address the above concerns.
” 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 Assign the Referral Co-ordinator responsibility for booking further initial assessment appointments after non-attendance.
Verbatim wording from the response “Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. This measure reduces the risk of a patient not being followed up as highlighted the North West Sussex Referral, Triage, Assessment and Allocation Process Map attached.” Source location 2021-0136-Response-from-Sussex-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 weekly administrative support to identify all DNA cases.
Verbatim wording from the response “The requirement to notify the GP is stated in our Active Engagement Did Not Attend (DNA) Management Policy. This requirement was outlined in our Serious Incident Report as an action. The action is complete and the practice embedded. Weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS due to repeated non-attendance and or engagement.” Source location 2021-0136-Response-from-Sussex-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 Notify GPs when patients are discharged from Horsham ATS because of repeated non-attendance or non-engagement.
Verbatim wording from the response “The requirement to notify the GP is stated in our Active Engagement Did Not Attend (DNA) Management Policy. This requirement was outlined in our Serious Incident Report as an action. The action is complete and the practice embedded. Weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS due to repeated non-attendance and or engagement.” Source location 2021-0136-Response-from-Sussex-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 Audit compliance with the strengthened referral follow-up arrangements over the forthcoming months.
Verbatim wording from the response “The safety of patients referred to us is of paramount importance to the Trust. Our service cannot coerce engagement as the desire to engage must come from the patient themselves, particularly when they are capacious, like Hannah was. However, it is important for our systems to be effective and to ensure that no patient “falls” between services. I trust this letter demonstrates to you and Hannah’s family the action we took to strengthen our systems. I will ensure we audit compliance with this over forthcoming months.” Source location 2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Open published response
15 Mar 2021 Timothy Julian STEELE · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 5 Inefficient ATS follow-up processes View source Staff lack of awareness of how matters are dealt with across Sussex View source Failure to appoint a Lead Practitioner when urgently needed View source Failure to follow Care Programme Approach guidance View source Fragmented and geographically inconsistent policies and practices View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Timothy Julian STEELE · 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
Timothy Julian STEELE was a 28-year-old man with a lifelong history of low mood, depression and suicidal ideation, who made multiple suicide attempts during 2020 and died at his home in Brighton on 10 August 2020. The report identified concerns that his referral was lost, that he was not followed up because of inefficient processes and failure to appoint a Lead Practitioner promptly, and that the Care Programme Approach was not followed. It also identified a fragmented approach to policies across different areas of Sussex.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inefficient ATS follow-up processes
Wider context from the report “(1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Staff lack of awareness of how matters are dealt with across Sussex
Wider context from the report “(2) In addition Sussex Partnership Foundation Trust appears to take a fragmented approach to its policies. Business is conducted in one way in Brighton and in another way, for example, in East or West Sussex and yet patients could be in Sussex depending on availability. They would apparently be dealt with differently depending on their geographic location.
At Tim Steele’s Inquest it was clear that staff members were not aware o how matters would be dealt with in other parts of Sussex .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a Lead Practitioner when urgently needed
Wider context from the report “(1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him . In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow Care Programme Approach guidance
Wider context from the report “(1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented and geographically inconsistent policies and practices
Wider context from the report “(2) In addition Sussex Partnership Foundation Trust appears to take a fragmented approach to its policies . Business is conducted in one way in Brighton and in another way, for example, in East or West Sussex and yet patients could be in Sussex depending on availability. They would apparently be dealt with differently depending on their geographic location .
At Tim Steele’s Inquest it was clear that staff members were not aware o how matters would be dealt with in other parts of Sussex.
” Open source report
15 Mar 2021 James Kenneth Herbertson · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 11 Failure to include and inform the primary support practitioner in discharge arrangements View source Lack of mechanism to notify service users when lead practitioners are unavailable View source Failure to inform family supporters of discharge View source Failure to assign responsibility for risk management and crisis referral View source Inadequate assessment and recording of service-user risk View source Failure to notify vulnerable service users’ parents of discharge View source Failure to provide safe and therapeutic post-discharge accommodation View source Inadequate recording of deterioration in mental health presentation View source Lack of staff understanding of actions required after Red Zone placement View source Provision of accommodation that is not a safe and therapeutic environment View source Failure to include and alert the primary lead practitioner in discharge arrangements View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Kenneth Herbertson · 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
James Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include and inform the primary support practitioner in discharge arrangements
Wider context from the report “a) The discharge arrangements from Langley Green Hospital did not include the Lead Practitioner who was going to be the primary contact responsible for providing the support to James following discharge. Although she had met him once no therapeutic relationship had been established and at the point of discharge, she was not aware that discharge had taken place .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mechanism to notify service users when lead practitioners are unavailable
Wider context from the report “a) The use of Text messaging is a good way of communicating between the Trust staff and a Service User particularly when they require assistance. However, Service users can place a reliance on this method of communication. It is therefore unfortunate that there is no mechanism to notify a service user that their lead practitioner is unavailable (due to leave or other work commitments) to deal with their message. Technology may not currently provide for an automatic “unavailability” response however this does leave service users vulnerable if they are in need of urgent help.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family supporters of discharge
Wider context from the report “b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for risk management and crisis referral
Wider context from the report “c) His lead practitioner was not available at the time and nobody appears to have taken responsibility to manage James’ risk or make a referral to the crisis team .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment and recording of service-user risk
Wider context from the report “b) James’ risk was not adequately accessed or recorded in his medical records following him being placed in the “Red Zone”.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify vulnerable service users’ parents of discharge
Wider context from the report “b) Although James was vulnerable his parents were also not aware of his discharge at the point of discharge and therefore were unable to offer support .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe and therapeutic post-discharge accommodation
Wider context from the report “c) The accommodation offered to James both on leaving hospital (and subsequently) was not a safe and therapeutic environment for a person who had recognised mental health difficulties with a history of alcohol and substance misuse. Whilst accommodation is a matter for the Local Authority the Trust staff work with partner agencies in the planning for a S17 discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of deterioration in mental health presentation
Wider context from the report “a) It was clear that James’ Mental health was deteriorating on the visit by the lead practitioner on 8th April 2019. This change in presentation was discussed at the Multidisciplinary meeting on 9th April 2019 but was not adequately recorded . He was placed in “Red Zone”. It was clear from the evidence that there was a lack of understanding by individual staff as to what actions they should be taking following a service user being placed in “Red Zone”.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding of actions required after Red Zone placement
Wider context from the report “a) It was clear that James’ Mental health was deteriorating on the visit by the lead practitioner on 8th April 2019. This change in presentation was discussed at the Multidisciplinary meeting on 9th April 2019 but was not adequately recorded. He was placed in “Red Zone”. It was clear from the evidence that there was a lack of understanding by individual staff as to what actions they should be taking following a service user being placed in “Red Zone” .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of accommodation that is not a safe and therapeutic environment
Wider context from the report “c) The accommodation offered to James both on leaving hospital (and subsequently) was not a safe and therapeutic environment for a person who had recognised mental health difficulties with a history of alcohol and substance misuse. Whilst accommodation is a matter for the Local Authority the Trust staff work with partner agencies in the planning for a S117 discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include and alert the primary lead practitioner in discharge arrangements
Wider context from the report “a) The discharge arrangements from Langley Green Hospital did not include the Lead Practitioner who was going to be the primary contact responsible for providing the support to James following discharge. Although she had met him once no therapeutic relationship had been established and at the point of discharge, she was not aware that discharge had taken place .
” 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 Reduce required post-discharge follow-up contact from seven days to three days under the Care Programme Approach policy.
Verbatim wording from the response “The Trust agrees that it is best practice for the Lead Practitioner to be actively involved in the acute care discharge process and to ensure that contact is made within 3 days of discharge for follow up; as per the Care Programme Approach policy version 7 March 2020 (current policy appendix 1). At the time of James' discharge, the policy in place (version 6 appendix 2 2017) was for a 7 day follow up, but due to the requirement to improve outcomes, this was reduced in 2020 to a 3 day follow up.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-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 Monitor risk assessments and care plans through monthly reviews to assure compliance.
Verbatim wording from the response “and suicide prevention. In November 2020, a new induction pack was in place for new starters with leadership support. Ongoing monitoring through monthly review of risk assessment and care plans continues to provide assurance of compliance.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-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 Introduce a revised Horsham ATS induction pack covering collaborative care planning, risk assessment, safety management and suicide prevention.
Verbatim wording from the response “As an outcome of the SI investigation, the Trust understood the requirement for Lead Practitioners to have induction, training and supervision in order for them to be able to identify when risk assessments should be updated and reviewed.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-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 daily-meeting documentation and audit clinical records to verify recording of identified risk, actions and responsible staff.
Verbatim wording from the response “from the SI investigation the Trust reviewed the documentation of daily meetings, and completed an audit of the Carenotes noted by the service to ensure adherence. The documentation had to include the identified risk, plan of action and who was undertaking the action. The updated audit of November 2020 illustrated above 97% compliance to the specified requirements.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-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 The Lead Practitioner was aware of the planned discharge and was notified, contrary to the concern that she was unaware.
Verbatim wording from the response “To confirm, James’ Lead Practitioner was aware that he was to be discharged (as per Lead Practitioner statement, Clinical records and Serious Incident report) as the Lead Practitioner had attended the Section 117 discharge aftercare meeting on the 02.08.2018 and on the Ward which James attended, alongside his Lead Practitioner.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-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 Accommodation access and organisation were considered the Local Authority’s responsibility, although Trust staff assisted with referrals and discharge planning.
Verbatim wording from the response “c) Accommodation on discharge was not safe or therapeutic for a person who had a recognised mental health difficulty. Whilst accommodation is a matter for the Local Authority the trust staff work with partner agencies in planning for 117 discharge.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Care Programme Approach policy and multidisciplinary discharge arrangements were considered sufficient for Lead Practitioner involvement and follow-up.
Verbatim wording from the response “The Trust agrees that it is best practice for the Lead Practitioner to be actively involved in the acute care discharge process and to ensure that contact is made within 3 days of discharge for follow up; as per the Care Programme Approach policy version 7 March 2020 (current policy appendix 1). At the time of James' discharge, the policy in place (version 6 appendix 2 2017) was for a 7 day follow up, but due to the requirement to improve outcomes, this was reduced in 2020 to a 3 day follow up.” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policy and agreed crisis and contingency contacts were considered sufficient where messages to a Lead Practitioner might not receive a response.
Verbatim wording from the response “Concern Raised: message. Mobile Phone and Text Messaging policy” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
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 No further action was considered necessary on family involvement because confidentiality and consent governed information sharing, with contact attempted where consent permitted.
Verbatim wording from the response “Action Taken or Required
Where the hospital/Trust agrees communication with families/carers is central to treatment and clinical decisions, it also has to maintain patient confidentiality where an” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
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 Trust could not provide automatic responses to text messages because its information technology systems lacked that capability.
Verbatim wording from the response “Response to text messaging when Lead Practitioner is not available/ does not see the” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
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 Ongoing audits of red-zone risk recording and crisis referral arrangements were considered sufficient, so no additional action was required.
Verbatim wording from the response “The Serious Incident report highlights the Care and Service delivery problem that the service ‘did not appear to have considered a referral to the crisis team despite clear signs of relapse and concerns raised by family’. In addition, that ‘there was no documented evidence of this discussion’. As an action” Source location 2021-0078-Response-from-Sussex-Partnership-NHS-Foundation-Redacted
Open published response
14 Dec 2020 Christopher Swain · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Failure to provide clear and consistent requirements for hourly observations of patients in their rooms View source Failure to maintain nursing and clinical records in accordance with policy View source Failure to provide or record therapeutic engagement View source Failure to provide staff to accompany sectioned patients to another hospital for physical treatment View source Lack of formal mental-health review View source Lack of mental-health care planning View source Failure to carry out adequate mental-health risk assessments 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
Christopher Swain · 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
Christopher Swain, who was detained under Section 3 of the Mental Health Act 1983, was found unresponsive in his room at Langley Green Hospital on 22 September 2019 with a ligature around his neck and was confirmed deceased by paramedics. Concerns included inconsistent staff practices when conducting observations, uncertainty about when he was last seen alive, the absence of a formal mental health review, care plan and adequate risk assessment, inadequate record-keeping, no recorded therapeutic engagement, and failure to provide staff to accompany a sectioned patient to another hospital.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent requirements for hourly observations of patients in their rooms
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms . There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff .
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy.
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nursing and clinical records in accordance with policy
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff.
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy .
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or record therapeutic engagement
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff.
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy.
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff to accompany sectioned patients to another hospital for physical treatment
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff.
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy.
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition . Requesting family member to undertake this role puts the patient and/or the family at 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal mental-health review
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff.
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review , care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy.
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mental-health care planning
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff.
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy.
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out adequate mental-health risk assessments
Wider context from the report “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff.
b) Following the evidence the Jury concluded:-
(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health.
(b) that the nursing and clinical records were not kept in accordance with the trust health and record policy.
(c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay.
Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case.
c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at 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 Conduct daily risk-assessment, huddle and clinical-notes audits with Ward Manager oversight from senior leadership.
Verbatim wording from the response “There have, since Christopher's death, been daily risk assessment audit, daily huddles as well as notes audits by Ward Managers with oversight by the senior leadership team. These audits demonstrate as of December 2020 there is 100% adherence to the training in quality record keeping.” Source location 2020-0284-Response-from-Sussex-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 inpatient care plans, risk assessments and clinical documentation, and maintain compliance through audits and competency plans.
Verbatim wording from the response “The absence of clinical documentation for Christopher during his admission to Langley Green Hospital was not completed to an expected standard in accordance with Trust Policy. The Trust therefore completed a review of professional conduct of all the staff involved in Christopher’s care through HR processes and made referrals to relevant Regulatory bodies. The Langley Green Hospital Leadership team and Trust took immediate action to prevent reoccurrence of any non-compliance with Trust Policy including an immediate review of all care plans, risk assessments and clinical documentation. This has been maintained through audit and competency plans. Feedback was given to the whole team by the Trust Deputy Chief Nurse due to the seriousness and the immediate requirement to reflect and improve.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 staff safety days with training on clinical risk assessment, professional responsibility, accountability and clinical curiosity.
Verbatim wording from the response “Staff were supported with safety days which commenced in December 2019 with specific training on Clinical Risk Assessment which focusses on professional responsibility, accountability, and clinical curiosity.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 Refresh observation guidance and provide all staff with pocket reference cards supporting safe observation practice.
Verbatim wording from the response “i. Guidance on observations was refreshed to support staff competency and implementation. All staff now have a pocket guide z card on conducting observations, this can be utilised as an aide memoire and reference guide.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 Display easy-read observation guidance posters on all inpatient wards.
Verbatim wording from the response “ii. An easy read poster guide on observations is also now available on all inpatient wards.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 Introduce a Trust-wide nursing competency framework and checklist requirements for documenting patient activity on observation charts.
Verbatim wording from the response “A new competency framework has been developed and introduced Trust wide to strengthen our systems and processes which reinforces the requirement of stating on the observation chart, the activity of the patient rather than ticking to evidence their presence on the ward. Each member of the Trust inpatient Nursing Team has been required to individually complete the competency check list and such is now integral to the Bank and Agency staff induction checklists - Trust-wide. There is particular focus on this point included in the Eight Steps to Quality and Safety poster now present in the nursing offices across the Trust acute wards. The evidence of all Langley Green Hospital staff completion and ongoing adherence to the requirement for each staff member to complete the induction checklist, which includes observations, has already been submitted to the Court.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 inpatient staff to complete note-writing competency checks and monitor adherence through weekly audits and daily spot checks by Ward Managers.
Verbatim wording from the response “Therefore, a review of all the professional conduct of the staff involved was completed at the time and managed through appropriate internal processes including HR and referrals to relevant Regulatory bodies. From a systems perspective, all Trust inpatient staff have completed competency checks in note writing and ongoing adherence is monitored by Ward Managers who check the content of patient notes weekly in audit form and complete spot checks on a daily basis.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 mandatory observation training and competencies, requiring annual completion and induction completion before agency or bank staff shifts.
Verbatim wording from the response “iii. Training and competencies on completing observations has been updated. This training is mandatory and must be completed annually and at induction for all agency and bank staff before they are able to commence a shift. There has been evidence submitted of staff completion and ongoing adherence to the requirement for each staff member to complete the induction checklist which includes observations. As of December 2020 there is a 100% compliance for staff who have completed training in Therapeutic Engagement and Observation competency assessments at Langley Green Hospital.” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
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 No policy changes were considered necessary because the incident resulted from staff failing to adhere to the existing Therapeutic Engagement and Observation Policy.
Verbatim wording from the response “In light of the clinical care review conducted in the wake of Christopher’s death, the Trust reconsidered its Therapeutic Engagement and Observation Policy. I and my Clinical, Operational and Service Directors were satisfied that no changes to Policy were required. The issue that arose in Christopher’s care was quite clearly, a lack of adherence to Trust Policy by staff. To prevent reoccurrence of non-compliance with Trust Policy within Langley Green Hospital and elsewhere within the Trust, the following actions were taken across all inpatient services:” Source location 2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Open published response
23 Nov 2020 Elena WELLS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Lack of clear allocation of overall responsibility for care View source Failure to provide advice about the available place of safety View source Lack of a clear inter-organisational working policy View source Failure to provide routine out-of-hours review and support for patients awaiting urgent admission 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
Elena WELLS · 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
Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear allocation of overall responsibility for care
Wider context from the report “1. Both the Local Authority and the Trust were involved in the care of Miss Wells for the last 24 hours of her life. Evidence showed that there was a grey area in respect of responsibility for her care, at this time. There was no clear guidance as to who held overall responsibility for her care and there was no clear policy of how the two organisations should work together in these kinds of situations. It is requested that the Local Authority and the Trust consider how to improve communication and clearly define responsibility between the two organisations which could improve the safety of patients with serious mental health difficulties who were waiting for urgent admission to a mental health 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice about the available place of safety
Wider context from the report “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital . Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear inter-organisational working policy
Wider context from the report “1. Both the Local Authority and the Trust were involved in the care of Miss Wells for the last 24 hours of her life. Evidence showed that there was a grey area in respect of responsibility for her care, at this time. There was no clear guidance as to who held overall responsibility for her care and there was no clear policy of how the two organisations should work together in these kinds of situations . It is requested that the Local Authority and the Trust consider how to improve communication and clearly define responsibility between the two organisations which could improve the safety of patients with serious mental health difficulties who were waiting for urgent admission to a mental health 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide routine out-of-hours review and support for patients awaiting urgent admission
Wider context from the report “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team , and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so . It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found.
” 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 Finalise the Trust-wide CRHT operational policy, including referral pathways and defined responsibilities for services supporting patients awaiting admission.
Verbatim wording from the response “In response, the Trust is in the process of developing a new Crisis Resolution Home Treatment Team (CRHT) Operational Policy. An interim policy was presented to the Operational Management Board in December 2020 and it was agreed the CRHT teams would work to this whilst the policy is further developed by the newly appointed Trust wide Urgent Care Pathway Lead.” Source location 2020-0248-Responses-from-Sussex-Partnership-Foundation-NHS-Trust-and-Brighton-Hove-City-Council-Redacted..pdf
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 Run a daily Urgent Demand Oversight meeting to review admission demand, available resources and support packages for patients awaiting hospital care.
Verbatim wording from the response “Locally, the Care Delivery Services [CDS] in Brighton has established an Urgent Demand Oversight meeting that enables the CDS Leads to have daily oversight of our patients requiring admission to hospital. This meeting is informed by the various Operational meetings that take place daily in our Community, Urgent and Acute Care Services and is described in the enclosed Terms of Reference (appendix 1).” Source location 2020-0248-Responses-from-Sussex-Partnership-Foundation-NHS-Trust-and-Brighton-Hove-City-Council-Redacted..pdf
Open published response
16 Mar 2020 John Ashley · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 9 Failure to update Care and Treatment Plans when mental health deteriorates View source Failure of the Liaison Mental Health Team to use patients’ Care and Support Plans and Central Risk Assessments View source Failure of weekly professional team meetings to review mental health deterioration and medication non-compliance View source Lack of a system to notify Lead Practitioners of actionable CareNotes entries View source Lack of a clear procedure for Care Coordinators to update GPs about changed treatment plans View source Lack of practitioner cover and formal handover arrangements for Lead Practitioner caseloads during leave View source Inconsistent policy requirements for timing of Risk Assessment reviews View source Failure to provide regular Psychiatrist review View source Failure to record and compile key patient information in CareNotes View source See 6 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. 6
Position
The team-wide duty system is considered safer and sufficient than assigning leave cover to one individual practitioner.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Not all email correspondence is routinely uploaded; recording the substance of relevant contact is considered sufficient.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Although Carenotes lacks automatic alerts, existing information-sharing processes are considered sufficient for required clinical communication.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Whether to discuss a patient at weekly MDT meetings is left to clinical judgment because experienced staff may review care without MDT discussion.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing practice of sending GPs clinical letters, care plans and relevant assessment information is considered sufficient for treatment-plan updates.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The MHLT's own assessment format, including risk and action-plan sections, is considered sufficient instead of using the patient's other care plans.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 5 more positions
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AI-generated summary
John Ashley · 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
John Ashley took his own life while suffering a deterioration in his mental illness, according to the inquest conclusion. The report identified concerns about failures to update his care and treatment plan, record and share key information, review his deterioration and medication non-compliance, and provide adequate clinical oversight and cover arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update Care and Treatment Plans when mental health deteriorates
Wider context from the report “1. Mr Ashley’s Care and Treatment Plan was not updated when his mental health deteriorated .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Liaison Mental Health Team to use patients’ Care and Support Plans and Central Risk Assessments
Wider context from the report “7. The Inquest heard evidence that the Liasion Mental Health Team at the Hosptial did not make use of patient’s Care and Support Plans or Central Risk 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of weekly professional team meetings to review mental health deterioration and medication non-compliance
Wider context from the report “4. Mr Ashley had not been seen by a Psychiatrist for over a year and there was no evidence that the deterioration of his mental health (and his non compliance with his medication) had been reviewed by the professionals weekly team meetings .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to notify Lead Practitioners of actionable CareNotes entries
Wider context from the report “3. There was no system in place for Lead Practitioners to be notified of an important entry in a patient’s CareNotes where action was required .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear procedure for Care Coordinators to update GPs about changed treatment plans
Wider context from the report “8. There was no clear procedure for GPs to be updated by Care Coordinators with details of a patient’s current treatment plan if it had been changed . This was particularly important where there was no regular assessments by a Psychiatrist who would in the normal course of events be providing such updates.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practitioner cover and formal handover arrangements for Lead Practitioner caseloads during leave
Wider context from the report “6. Save for the duty scheme there appears to be no procedure in place for another practitioner to cover a Lead Practitioner’s case load or any formal handover when they are on leave . Therefore there was no single person who has up todate knowledge of a patient who may be in need or whose mental health was deteriorating .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent policy requirements for timing of Risk Assessment reviews
Wider context from the report “5. The Inquest identified that there was a discrepancy in the Trust’s own Policies as to when a Risk Assessment should be reviewed .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular Psychiatrist review
Wider context from the report “4. Mr Ashley had not been seen by a Psychiatrist for over a year and there was no evidence that the deterioration of his mental health (and his non compliance with his medication) had been reviewed by the professionals weekly team meetings.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and compile key patient information in CareNotes
Wider context from the report “2. Staff were not recording interactions with Mr Ashley in the CareNotes system and often emails were not copied into these notes . Therefore there was a lack of compilation of key information relating to Mr Ashley .
” 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 Appoint two substantive Consultant Psychiatrists and support them with an Associate Specialist.
Verbatim wording from the response “Mr Ashley did have a medical review/telephone consultation with a Consultant Locum Consultant Psychiatrist on 30 October 2018 when there was a concern about his health. I regret that Mr Ashley was not seen by a Psychiatrist as regularly as he should have been i.e annually, however I can report that the Trust has successfully appointed two substantive Consultant Psychiatrists for Worthing this year, and they joined the team in March. They are supported by an Associate Specialist. This will enable us to facilitate medical reviews in a timely manner and negate the need for a waiting list. The medical caseload is currently being reviewed with a view to ensuring that every patient has an annual medical review as required.” Source location 2020-0071-Sussex-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 Continue monitoring compliance with care plans, risk assessments and supervision through performance reporting and audits.
Verbatim wording from the response “The Trust monitors performance in each of these areas and there are individual performance dashboards for each team within the Carenotes system that allow clinicians to monitor their own performance when they log onto the system. Team Leaders and other managers also have access to team/service based reports through our "Report Manager" performance system and these provide an audit function and allow managers to have an overview of team performance.” Source location 2020-0071-Sussex-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 Revise care plan formats and processes to improve care standards.
Verbatim wording from the response “The Trust is continuing to monitor compliance with care plans, risk assessments and supervision and since autumn last year, we have revised our care plan and risk assessment formats/processes, updated our policies and training programme to improve standards of care.” Source location 2020-0071-Sussex-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 medical caseload to ensure patients receive annual medical reviews as required.
Verbatim wording from the response “Mr Ashley did have a medical review/telephone consultation with a Consultant Locum Consultant Psychiatrist on 30 October 2018 when there was a concern about his health. I regret that Mr Ashley was not seen by a Psychiatrist as regularly as he should have been i.e annually, however I can report that the Trust has successfully appointed two substantive Consultant Psychiatrists for Worthing this year, and they joined the team in March. They are supported by an Associate Specialist. This will enable us to facilitate medical reviews in a timely manner and negate the need for a waiting list. The medical caseload is currently being reviewed with a view to ensuring that every patient has an annual medical review as required.” Source location 2020-0071-Sussex-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 Complete ratification and publication of the revised clinical risk assessment and safety planning policy.
Verbatim wording from the response “The Trust accepts that the current Clinical Risk Assessment and Safety Planning/ Risk Management Policy and Procedure policy is unclear as it has two potential review dates when the risk assessment should be updated. The current policy is under review and this has been addressed as part of that. The new policy is in the final stages of ratification and will be available for staff very shortly.” Source location 2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate leave handover arrangements, particularly for vulnerable patients, into staff risk assessment training.
Verbatim wording from the response “I acknowledge that in this case, it was a specific concern that a Lead Practitioner when returning from leave should be aware of important developments regarding his/her patient. It is the responsibility of a Lead Practitioner and other members of staff returning from leave, to review their caseload and establish if there were any concerns during their absence and I understand that Mr Ashley's Lead Practitioner did make himself aware of events when he returned from leave (he addressed this in his addendum report at the Inquest). Nevertheless, I wish to reassure you, that I agree that it is important that there should be a handover following a leave of absence, particularly in the case of the most vulnerable patients and staff are actively encouraged to ensure that this takes place and this will become part and parcel of staff risk assessment training.” Source location 2020-0071-Sussex-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 The team-wide duty system is considered safer and sufficient than assigning leave cover to one individual practitioner.
Verbatim wording from the response “This concern was addressed in my letter of 20 December 2019 wherein I sought to convey that Mr Ashley was treated as part of a team, and that a plan was in place (as part of his overall care plan), to ensure that there was adequate support when his Lead Practitioner was not available. Prior to going on leave, I understand that Mr Ashley's Lead Practitioner visited to discuss cover arrangements and his crisis/contingency plan. It is apparent that Mr Ashley understood the arrangements as he attended his planned appointments at the Wellbeing Café and Clozaril Clinic, and he accessed the duty system and the Mental Health Liaison Team for further support.” Source location 2020-0071-Sussex-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 Not all email correspondence is routinely uploaded; recording the substance of relevant contact is considered sufficient.
Verbatim wording from the response “It is standard practice for all interactions with patients to be recorded on the Carenotes system and these records are available and accessible to clinicians in all parts of our service to review. In the case of Mr Ashley, it was evident that our acute and community services used his health records to share information, make clinical decisions and review his care. However, I understand that you had specific concerns that email correspondence from Mr Ashley's sister, was not uploaded to his record. I would advise that it is not customary practice to upload all email correspondence. However, the Trust would expect a record and detail of ████████ contact to be recorded on the system.” Source location 2020-0071-Sussex-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 Although Carenotes lacks automatic alerts, existing information-sharing processes are considered sufficient for required clinical communication.
Verbatim wording from the response “I acknowledge that our Carenotes system does not have an automatic function to alert Lead Practitioners and/or the clinical care team when another clinician has accessed a patient's records or recorded clinical activity. However, I would like to reassure you we have processes and procedures in place to allow clinicians to share information when” Source location 2020-0071-Sussex-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 Whether to discuss a patient at weekly MDT meetings is left to clinical judgment because experienced staff may review care without MDT discussion.
Verbatim wording from the response “In respect of your concern that Mr Ashley's condition was not discussed in the multidisciplinary (MDT) meetings, I would like to reassure you that MDT meetings occur weekly and Lead Practitioners and other colleagues are invited to present cases where they require advice and support, or cases which require a multidisciplinary approach. The decision as to whether a case should be discussed at a MDT meeting, is a matter of clinical judgment, and in Mr Ashley's case, his Lead Practitioner and others involved in his care, did not consider this support was necessary and his care was reviewed by the experienced staff who were directly involved in his care.
My understanding is that it is not common practice for every patient to be discussed at a MDT meeting.” Source location 2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing practice of sending GPs clinical letters, care plans and relevant assessment information is considered sufficient for treatment-plan updates.
Verbatim wording from the response “Mr Ashley should have had a medical review on an annual basis and I wish to assure you that it is our practice to send a clinical letter to the GP as well as a copy to the patient. It is also Trust practice to send a copy of the care plan and information about changes to medication or physical health assessments undertaken by our service. I am informed that the GP practice received copies of Trust letters from the last medical review and copies of the assessments undertaken by the Mental Health Liaison Team and these contained details of the perceived risk and action plan agreed with the patient.” Source location 2020-0071-Sussex-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 The MHLT's own assessment format, including risk and action-plan sections, is considered sufficient instead of using the patient's other care plans.
Verbatim wording from the response “I understand that ████████ was critical of the assessment undertaken by the MHLT and considered that they should have considered the care plans. I would like to explain that the MHLT has its own assessment format and this includes a risk assessment and action plan section and it is designed in this way for ease of sharing information with primary care. At the Inquest, I am informed that the MHLT Team Leader gave evidence as” Source location 2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
Open published response
10 Dec 2019 Bethany Tengquist · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 11 Absence of dedicated entrance security staff during patient and visitor arrival hours View source Lack of ward management and matron leadership View source Insufficient substantive staffing and reliance on bank and agency staff View source Inadequate emergency life support and first aid training for healthcare staff View source Lack of patient-centred involvement in care plan updating View source Failure to meaningfully update care plans View source Inadequate completion of accompanying documentation View source Inadequate shift handovers View source Failure to maintain an effective searching system for patients and visitors View source Incomplete and flawed checks and removal of dangerous items from patient rooms View source Failure to properly train staff to carry out patient room checks View source See 8 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
Bethany Tengquist · 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
Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of dedicated entrance security staff during patient and visitor arrival hours
Wider context from the report “1. The search policy and Beth’s access to alcohol on a frequent basis
Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward. The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive , gives rise to a risk of future deaths should alcohol continue to find a route onto the 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward management and matron leadership
Wider context from the report “5. Staffing levels.
It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time , in conjunction with a 50% reduction of substantive staff. There was a reliance on bank and agency staff, and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient substantive staffing and reliance on bank and agency staff
Wider context from the report “5. Staffing levels.
It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff . There was a reliance on bank and agency staff , and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate emergency life support and first aid training for healthcare staff
Wider context from the report “3. First aid training.
I am gravely concerned by the evidence that not all health care staff working on Caburn Ward were adequately trained in emergency life support or first aid . It is axiomatic that all members of health care staff must be competent and able to deal with circumstances were first aid skills may need to be deployed . At least one member of staff admitted that she did not have these skills even when she gave evidence to the jury, notwithstanding that she had been appointed as a substantive member of staff some seven months following the death, and three months before she gave evidence.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of patient-centred involvement in care plan updating
Wider context from the report “4. Care Plan not Up-dated.
It was accepted by the Trust that Beth’s Care Plan had not, contrary to requirements of the Care Programme Arrangement, been updated in any meaningful way throughout Beth’s three month section 3 detention prior to her death. As the Clinical Lead Nurse Manager conceded, in the absence of patient centred involvement in the up-dating of the Care Plan , it risks becoming “meaningless” to the patient. In circumstances where a co-authored and co-produced document that actively involves and engages the patient is simply not up-dated meaningfully at all, then the aims and purposes of the CPA risk being undermined. In the context of a patient with Beth’s co-morbidities, the impact may be very serious indeed. The jury’s conclusions in this respect are informative and clear.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully update care plans
Wider context from the report “4. Care Plan not Up-dated.
It was accepted by the Trust that Beth’s Care Plan had not, contrary to requirements of the Care Programme Arrangement, been updated in any meaningful way throughout Beth’s three month section 3 detention prior to her death. As the Clinical Lead Nurse Manager conceded, in the absence of patient centred involvement in the up-dating of the Care Plan, it risks becoming “meaningless” to the patient. In circumstances where a co-authored and co-produced document that actively involves and engages the patient is simply not up-dated meaningfully at all, then the aims and purposes of the CPA risk being undermined. In the context of a patient with Beth’s co-morbidities, the impact may be very serious indeed. The jury’s conclusions in this respect are informative and clear.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of accompanying documentation
Wider context from the report “2. Staff training and auditing.
The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation . I specifically require identification of the steps proposed to dramatically improve these matters.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate shift handovers
Wider context from the report “2. Staff training and auditing.
The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation. I specifically require identification of the steps proposed to dramatically improve these matters.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an effective searching system for patients and visitors
Wider context from the report “1. The search policy and Beth’s access to alcohol on a frequent basis
Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward . The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive, gives rise to a risk of future deaths should alcohol continue to find a route onto the 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete and flawed checks and removal of dangerous items from patient rooms
Wider context from the report “During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm.
The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed.
The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself.
Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them.
Please tell me precisely how you are going to put this right.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly train staff to carry out patient room checks
Wider context from the report “During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm.
The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed.
The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself.
Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them .
Please tell me precisely how you are going to put this right.
” Open source report
21 Nov 2019 George Edward Rogers · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Edward Rogers · 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
George Edward Rogers had a diagnosis of body dysmorphic disorder and died on 28 August 2018 after causing a fatal laceration to his chest. Following his transfer between care teams, a Lead Practitioner was not appointed promptly, resulting in a period without treatment or ongoing risk assessment. The principal concern was that such transfer arrangements could delay treatment and leave patients unmonitored.
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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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS
Wider context from the report “1. When transferring patients between the CRHTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment .
” 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 Monitor weekly patients transferred between teams who remain without an allocated Lead Practitioner.
Verbatim wording from the response “Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis.” Source location Response from Sussex 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 Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.
Verbatim wording from the response “The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner.” Source location Response from Sussex 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 There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.
Verbatim wording from the response “I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, if any further clarification is required or I can assist further in any way then please do not hesitate to contact me.” Source location Response from Sussex 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 Existing monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.
Verbatim wording from the response “If the patient is already known to the team, the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if” Source location Response from Sussex Partnership NHS Foundation Trust
Open published response
8 Mar 2019 John Peter RICHARDSON · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Lack of a specific leave policy for voluntary patients 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
John Peter RICHARDSON · 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
John Peter Richardson was admitted as a voluntary patient to Meadowfields Hospital with suicidal thoughts and went missing after leaving the hospital grounds on 3 February 2018. His body was found in woodlands on 4 February 2018, and death was confirmed at the scene. The report identified concerns including the absence of a further risk assessment and care plan, poor communication and record keeping, and confusion about his leave arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific leave policy for voluntary patients
Wider context from the report “(2) However the death of Mr Richardson appears to have occurred when there was some confusion amongst staff with regards to Mr Richardson’s leave status . This was identified by the Jury in their conclusion. Whilst some guidance is provided to staff, with regards to voluntary patients taking leave, there is no specific Leave Policy for Voluntary Patients in the same way as there is one for those patients sectioned under the Mental Health Act.
” 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 Include guidance on voluntary patients leaving wards in the new Acute Care Operational Policy.
Verbatim wording from the response “Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff’s understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. I have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further stand-alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required.” Source location 2019-0084-Response-by-Sussex-Partnership-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further standalone policy is considered necessary because the principles are incorporated into the new Acute Care Operational Policy.
Verbatim wording from the response “Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff’s understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. I have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further stand-alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required.” Source location 2019-0084-Response-by-Sussex-Partnership-NHS-Trust
Open published response
6 Dec 2018 John Michael KIRBY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 11 Failure to record the consultation about the impact of the ADHD diagnosis View source Failure to consider relevant substance use and suicide risk before prescribing Concerta View source Failure to recognise and act on recorded information about suicidal intent View source Failure to follow NICE guidance for ADHD management View source Failure to properly monitor Concerta treatment View source Inappropriate ADHD assessment and prescribing suggestion View source Failure to inform the GP of the ADHD diagnosis View source Delays in dealing with the patient View source Prescribing Concerta without further clinical review View source Failure to obtain sufficient details of a reported suicide attempt View source Failure to discuss the ADHD diagnosis with the immediate next of kin View source See 8 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
John Michael KIRBY · 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
John Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the consultation about the impact of the ADHD diagnosis
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider relevant substance use and suicide risk before prescribing Concerta
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking . This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on recorded information about suicidal intent
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die” .
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidance for ADHD management
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance , inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly monitor Concerta treatment
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate ADHD assessment and prescribing suggestion
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta .
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of the ADHD diagnosis
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP , start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in dealing with the patient
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018 .
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Prescribing Concerta without further clinical review
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain sufficient details of a reported suicide attempt
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin.
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke ?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss the ADHD diagnosis with the immediate next of kin
Wider context from the report “(1) The delay in dealing with Mr Kirby between August 2017 and March 2018.
(2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.
(3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin .
(4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E.
This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE.
(5) Why was Mr Kirby prescribed Concerta without any (further) review?
(6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?
(7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”.
(8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke?
” 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 Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.
Verbatim wording from the response “As your concern centres on clinical decision-making I asked the Trust’s Chief Medical Officer ████████ to set up a group of senior medical colleagues to review ████████ medical practice in relation to ADHD. The terms of reference of that medical decision-making group (DMG) included consideration of the use of ADHD questionnaires for diagnosis as well as consideration of the assessment and diagnosis of ADHD and recommended prescribing.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-manage all ADHD patients with the Neurobehavioural Team to provide ongoing monitoring.
Verbatim wording from the response “An immediate action that was taken was to ensure that all ████████ ADHD patients were co-managed with the Neurobehavioural Team. Additionally, a clinical review of all ADHD prescribing within the relevant team was completed which, I am pleased to say, did not identify any concerns.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share ADHD NICE guidance with all doctors through the Mediconnect intranet forum.
Verbatim wording from the response “In addition to the above, the DMG took a number of further steps to establish wider learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect which is our doctors’ intranet forum for highlighting items of importance/interest/learning etc. Additionally, the issues arising from this case are to be presented for learning and discussion at the Trust’s forthcoming Effective Care & Treatment Conference next month. Furthermore, we are to publish a story, based on this case and to specifically include the issues surrounding co-morbid substance misuse, in our Patient Safety Matters; this is an internal learning publication that we use to improve patient safety.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain specialist review of ADHD practice and repeat training on NICE guidance and the local shared-care protocol.
Verbatim wording from the response “An outcome of the DMG review was to seek assistance from Professor ████████ (Chair in Psychiatry, University of Sussex) who has agreed to review Mr Kirby’s case with ████████ on 25 March 2019 and recommend any training needs, focussing on using NICE guidance and local shared care protocol for ADHD cases.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a Patient Safety Matters story covering the case and issues surrounding co-morbid substance misuse.
Verbatim wording from the response “In addition to the above, the DMG took a number of further steps to establish wider learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect which is our doctors’ intranet forum for highlighting items of importance/interest/learning etc. Additionally, the issues arising from this case are to be presented for learning and discussion at the Trust’s forthcoming Effective Care & Treatment Conference next month. Furthermore, we are to publish a story, based on this case and to specifically include the issues surrounding co-morbid substance misuse, in our Patient Safety Matters; this is an internal learning publication that we use to improve patient safety.” Source location 2018-0379-Response-by-Sussex-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 Reduce the Lead Practitioner’s caseload and provide robust ongoing caseload review and supervision.
Verbatim wording from the response “The recommended measures to address those failings involved establishing that Mr Kirby’s Lead Practitioner’s caseload was such that he had sufficient capacity to ensure an appropriate level of care was delivered and that there be greater oversight and management of his caseload. I confirm that those measures were and continue to be taken. Specifically, there has been a significant reduction in his caseload coupled with robust and ongoing review of that caseload and supervision to secure that he is fully supported to deliver the level of care that is expected.” Source location 2018-0379-Response-by-Sussex-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 Create an information-sharing protocol between the Mental Health Liaison Team and Pavillions A&E liaison service.
Verbatim wording from the response “I am informed that the evidence at the Inquest showed that Mr Kirby provided the Pavillions A&E liaison nurse with this suicide attempt information but that our Mental Health Liaison nurse was not aware of it. As this has identified a gap in the working between the two services the manager responsible for our Mental Health Liaison Team has worked with her Pavillions counter-part to create an information sharing protocol” Source location 2018-0379-Response-by-Sussex-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 Complete a clinical review of ADHD prescribing within the relevant team.
Verbatim wording from the response “An immediate action that was taken was to ensure that all ████████ ADHD patients were co-managed with the Neurobehavioural Team. Additionally, a clinical review of all ADHD prescribing within the relevant team was completed which, I am pleased to say, did not identify any concerns.” Source location 2018-0379-Response-by-Sussex-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 The A&E attendance did not heighten concern because the presentation was previously seen with alcohol use and liaison staff did not recommend re-referral.
Verbatim wording from the response “████████ informs me that he reviewed the details of Mr Kirby’s A&E admission upon receipt of the letter from the GP seeking the prescribing advice. His clinical opinion at that time was that Mr Kirby’s presentation at A&E was not new; that is to say that he had previously presented similarly when under the influence of alcohol. ████████ also took into account that Mr Kirby was assessed by the Mental Health Liaison Team who didn’t consider re-referring him. Therefore ████████ concern for Mr Kirby was not heightened by this attendance at A&E.” Source location 2018-0379-Response-by-Sussex-NHS-Trust
Open published response
18 Jan 2018 Paul Lawrence Hanton · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Failure to make appropriate referrals to other police forces View source Lack of consolidated information for AWOL emergency calls View source Failure to clearly record the initial risk assessment in the CAD View source Unequal police response to high-risk informal and sectioned patients View source Unclear AWOL policy on waiting for clinical staff discussion View source Delays in undertaking timely local police actions View source Unavailability of hospital CCTV for police viewing View source Lack of joint policy with the Adult Safeguarding Board View source See 5 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
Paul Lawrence Hanton · 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
Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate referrals to other police forces
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consolidated information for AWOL emergency calls
Wider context from the report “1) Need for clear information to be given by hospital staff when making the 999 call to report a patient has gone AWOL in order to proactively answer the known risk questions and maximise the opportunity for police to take timely action to trace the patient within the golden hour.
I heard from ████████ Service Director, that when a 999 call is made relevant information would need to be drawn from several sources including the patient’s form (personal/physical details & photo), any signing in/out form (last known clothing) and latest risk assessments/plan with details of recent incidents that inform the risk assessment. Inevitably, when a patient goes missing the AWOL policy needs to be followed including internal and external searches; notification of relevant senior staff etc. At times of pressure such as these it would be advisable to have all the relevant information in one location for ease of access by the designated person who makes the call.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record the initial risk assessment in the CAD
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unequal police response to high-risk informal and sectioned patients
Wider context from the report “6) Police to consider equal response to informal as well as sectioned patients if guided by clinical staff of high risk. I heard from senior staff at Langley Green that there is a discernibly different response from police when the missing person is an informal patient rather than under a MHA order . In the latter case, often a blue light police car is immediately dispatched to the hospital and a room/locality search takes place. This is not the case with an informal patient yet the same high risk of self-harm or suicide or risk of causing injuries to others may exist . In other words, there seems to be a general perception that informal patients are less unwell.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear AWOL policy on waiting for clinical staff discussion
Wider context from the report “3) Langley Green to consider review and amendment of current AWOL policy. This may be necessary given ████████ indication that he does not believe staff need to wait to have a discussion with clinical staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking timely local police actions
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of hospital CCTV for police viewing
Wider context from the report “2) Langley Green to ensure that hospital CCTV is accessible at all times for police viewing .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint policy with the Adult Safeguarding Board
Wider context from the report “5) Police to consider joint policy with Adult Safeguarding Board .
” Open source report
2 Aug 2017 Thomas Christall · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 3 Lack of local in-patient detoxification facility availability View source Failure to provide collaborative, integrated dual diagnosis treatment and assessment View source Delays in access to in-patient detoxification View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Christall · 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
Thomas Christall’s inquest concluded that he took his own life. Concerns included the lack of a local inpatient detoxification facility, long waiting times, and insufficiently collaborative treatment for people with dual diagnosis, with delays and refusals increasing distress and despair.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local in-patient detoxification facility availability
Wider context from the report “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital . It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK?
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide collaborative, integrated dual diagnosis treatment and assessment
Wider context from the report “(2) A much more collaborative approach to dual diagnosis patient's treatment is needed.
The dual diagnosis is at the heart of this problem. It is not appropriate to try to separate each component and only agree to treat/assess one component when the other is dealt with. The dual diagnosis is the person. When in crisis they are doubly at risk. That period of risk should be reduced as quickly as possible. The delays and refusals serve to exacerbate the patient's distress and increase their despair.
As Thomas Wall said in a text message to his supportive ex-wife
‘I want to get better but I can’t do that on my own whereas I can take my life on my own’
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to in-patient detoxification
Wider context from the report “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK?
” 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 Disseminated Public Health England guidance to relevant clinical and community service leads to inform teams’ dual-diagnosis service delivery.
Verbatim wording from the response “████████ Head of Legal Services, briefed me fully on the inquest of Mr Wall and I was heartened that you praised the substantial input to Mr Wall’s care from the Trust’s Assessment and Treatment Service, the Mental Health Rapid Response Service, the General Practitioner and Pavilions and acknowledged the difficulties faced by these services as mental health and substance misuse services are not managed by one local provider such as the Trust. Following the inquest, ████████ ensured that the informative Public Health England guidance shared at the inquest by ████████ was provided to the Clinical and Service Director for Brighton and Hove, ████████, and the General Manager for Community Services for Brighton and Hove, ████████ to ensure their teams are aware of the recent guidance to aid them in delivering services.” Source location 2017-0321-Response-by-Susssex-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 The Trust cannot provide local substance misuse services without being commissioned by Brighton and Hove City Council.
Verbatim wording from the response “The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and Hove were being provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who have mental health needs and substance misuse needs. Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service, Brighton and Hove City Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners.” Source location 2017-0321-Response-by-Susssex-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 Brighton and Hove City Council is responsible for commissioning local substance misuse services.
Verbatim wording from the response “The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and Hove were being provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who have mental health needs and substance misuse needs. Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service, Brighton and Hove City Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners.” Source location 2017-0321-Response-by-Susssex-Partnership-NHS-Trust
Open published response
14 Jul 2017 Sabrina Michelle Walsh · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of CCTV in corridors and communal areas for locating vulnerable patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sabrina Michelle Walsh · 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
Sabrina Michelle Walsh was detained under the Mental Health Act at Woodlands Acute Care and was found hanging with a ligature around her neck. The inquest concluded that she deliberately attached the ligature, but the evidence did not fully explain whether she intended a fatal outcome; this was contributed to by neglect. Concerns included the lack of formal risk assessment, inadequate observations and the absence of CCTV in corridors and communal areas.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV in corridors and communal areas for locating vulnerable patients
Wider context from the report “The lack of CCTV in corridors and communal areas at Woodlands Acute Care, St Leonards on Sea , which would enhance location of vulnerable patients where observations do not immediately locate them . Valuable minutes would be saved in locating vulnerable patients if CCTV was installed .
” 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 Install CCTV in the entrance areas of all 12 Acute Inpatient and PICU wards, including Woodlands.
Verbatim wording from the response “As a result of the information we now have available to us, I confirm that the Trust is in the process of implementing the installation of CCTV in the entrance areas of all our Acute Inpatient/PICU wards, which is a total of 12 sites, including Woodlands.” Source location 2017-0449-Response-by-Sussex-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 Intrusive CCTV in everyday communal living areas is not advisable; CCTV should be limited to entrances and main access pathways.
Verbatim wording from the response “The national steer from NHS England (which I’m aware is being forwarded directly to you), now states that CCTV would be advisable in the areas where people enter the unit and the main pathways in. However, it would not be advisable to have intrusive cameras in everyday areas such as common living areas shared by patients.” Source location 2017-0449-Response-by-Sussex-NHS-Trust
Open published response
4 Jul 2017 Janet Silva Müller · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Ability of patients detained under the Mental Health Act 1983 to abscond from the ward View source Failure to maintain complete, sufficient and consistent nursing records, handovers, risk assessments and care plans View source Inadequate staffing levels View source Failure of auditing of nursing records to identify documentation gaps 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.
×
AI-generated summary
Janet Silva Müller · 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
Janet Silva Müller, a patient detained under Section 2 of the Mental Health Act 1983 at Millview Hospital, died on 13 March 2015 after being found in the boot of a burning car; the circumstances were recorded as unlawful killing following her absconding from hospital. The principal concerns were incomplete and contradictory records, handovers, risk assessments and care plans, inadequate staffing, and insufficient measures to prevent detained patients from absconding.
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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ability of patients detained under the Mental Health Act 1983 to abscond from the ward
Wider context from the report “2. The ability of Patients detained under the Mental Health Act 1983 being able to abscond . Whilst it is accepted that the Hospital has now put in place further measures to prevent patients from being able to abscond from the ward, such as increasing the height of the garden walls and put into additional security around the entrance door, patients have still been able to abscond .
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete, sufficient and consistent nursing records, handovers, risk assessments and care plans
Wider context from the report “1. Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory . Whilst we were told that regular auditing is carried out by the Trust of nursing records it is clear that this is not fit for purpose as it is did not identify the fact that there were gaps in Janet’s nursing records and other key documents . The lack of proper record keeping increased Janet’s 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels
Wider context from the report “3. Staffing Levels – The Jury identified that at times the level of staffing was inadequate and this together with the lack of other measures put in place contributed to the risk of Janet absconding.
” 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 Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of auditing of nursing records to identify documentation gaps
Wider context from the report “1. Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory. Whilst we were told that regular auditing is carried out by the Trust of nursing records it is clear that this is not fit for purpose as it is did not identify the fact that there were gaps in Janet’s nursing records and other key documents. The lack of proper record keeping increased Janet’s risk.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations