17 Mar 2017 Trevor John CURRY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2 Failure to ascertain and access patients’ full past medical histories promptly View source Failure to record relevant disclosed cardiac history in psychiatric admission notes 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
Trevor John CURRY · 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
Trevor John CURRY died within 48 hours of admission to a psychiatric hospital. The concerns were that information about his heart problems was not recorded in his admitting note and that the trust did not obtain his full physical medical history until after his death, with particular concern about timely access to medical histories for psychiatric patients unable to provide them.
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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 ascertain and access patients’ full past medical histories promptly
Wider context from the report “(1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories.
In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff at the psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been.
In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily.
This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant disclosed cardiac history in psychiatric admission notes
Wider context from the report “(1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories.
In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff at the psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been.
In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily.
This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief staff on documentation concerns through Trust-wide communications, team meetings and clinical supervision.
Verbatim wording from the response “I am sorry, the information from Mr Curry’s sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. ████████, General Manager - Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met.” Source location Response from Sussex Partnership NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit ward documentation to check compliance with expected recording standards.
Verbatim wording from the response “I am sorry, the information from Mr Curry’s sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. ████████, General Manager - Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met.” 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 Circulate and display primary-care-information guidance and provide it to new junior doctors through induction materials.
Verbatim wording from the response “practice for all new patients admitted to Mill View hospital. This is done within 48 hours of admission and the administrators verify all new patient admissions at the daily Acute Referral Meeting (ARM) which is attended by the Bed Manager. The Crisis Resolution and Home Treatment Team administrators upload the primary care, summary care record / encounter report to the Trust’s electronic health records system ‘Carenotes’ which all clinical staff in the Trust have access to. Laminated copies of the guidance has been circulated to the wards at Mill View Hospital and it is displayed for staff as a reminder and for easy reference. Please find enclosed our new Protocol for the Management of Primary Care Clinical Information for all Patients admitted to acute inpatient services for your information.” 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 Operate a system requiring primary care records for new acute admissions within 48 hours, verifying requests and uploading records to Carenotes.
Verbatim wording from the response “In relation to the timely requests for primary care records and information about our patients, I am pleased to say a new system has been introduced. The new system, now in use is as follows; The Crisis Resolution and Home Treatment Team administrators request a copy of the primary care, summary care record, or encounter report, from the GP” 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 Develop an opt-out system informing patients that summary care record access will occur by default, subject to stated exceptions.
Verbatim wording from the response “In addition, ████████ (Chief Pharmacist) produced guidance for staff regarding the importance of obtaining the primary care, summary care record, which was distributed to Trust staff and taken to staff meetings for sharing and discussion. Clinicians in both primary and secondary care can access summary care records using an NHS Smartcard, once they are set up on the national system. Furthermore, the Trust is currently looking to establish an “opt out” system so that patients in contact with our services are informed that summary care record access will occur by default unless they specify that it may not, (unless a best interest decision needs to be made). ████████ (Chief Pharmacist) has confirmed that this guidance is now included in the induction pack for all new junior doctors joining the Trust.” Source location Response from Sussex Partnership NHS Foundation Trust
Open published response
14 Feb 2017 Derek LEE · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 26 Delays in referring patients to required specialist services View source Delays in review by a Parkinson’s nurse specialist View source Failure to assist patients with mobilising View source Failure to carry out prescribed saline eye cleaning View source Failure to record dates of specialist referrals View source Delays in administering required enemas View source Failure to make mobility central to the care plan View source Failure to complete requested patient re-weighing View source Failure to refer nutritionally deteriorating patients to dieticians View source Failure to adequately address the core medication regimen View source Failure to recognise deterioration in mobility View source Failure to hand over medical instructions and recommendations View source Failure to record reasons for medication changes View source Failure to incorporate family information into falls risk assessment View source Failure to properly assess mental capacity View source Delays in completing Waterloo pressure-risk scoring View source Lack of a coherent, considered and reviewed care plan View source Delays in completing thromboprophylaxis assessment View source Failure to maintain a timely bowel chart View source Failure to discuss medication changes View source Failure to review nutritional risk after reduced eating View source Failure to ensure timely provision and use of pressure-relieving equipment View source Failure to appoint a care coordinator under the Care Programme Approach View source Failure to regularly review original assessments View source Incomplete mental-capacity documentation at discharge View source Failure to respond to substantial weight loss View source See 23 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.
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AI-generated summary
Derek LEE · 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
Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.
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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 Delays in referring patients to required specialist services
Wider context from the report “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days . It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late.
” 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 review by a Parkinson’s nurse specialist
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” 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 assist patients with mobilising
Wider context from the report “(10) There was apparently no appreciation of the deterioration in Mr Lee’s mobility. He was at high risk of falls and yet the mobilisation of a Parkinson’s patient is imperative and also since he was being specialised during his entire admission there is absolutely no excuse for not trying to assist him with mobilising .
” 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 prescribed saline eye cleaning
Wider context from the report “(7) Medical instructions and recommendations were not handed over. One example relates to instructions to clean Mr Lee’s infected eyes with saline every two hours to keep them open. This was not done and when he arrived at the Acute Hospital his eyes were crusted shut.
” 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 dates of specialist referrals
Wider context from the report “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late.
” 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 administering required enemas
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” 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 mobility central to the care plan
Wider context from the report “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that.
” 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 requested patient re-weighing
Wider context from the report “(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating.
There was no evidence of any reaction to Mr Lee’s substantial weight loss.
There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take 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 Failure to refer nutritionally deteriorating patients to dieticians
Wider context from the report “(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating.
There was no evidence of any reaction to Mr Lee’s substantial weight loss.
There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take 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 Failure to adequately address the core medication regimen
Wider context from the report “(1) Mr Lee’s medication regimen which was to be the core of the admission was barely addressed and no reasons for any changes in medication appear in his 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 recognise deterioration in mobility
Wider context from the report “(10) There was apparently no appreciation of the deterioration in Mr Lee’s mobility. He was at high risk of falls and yet the mobilisation of a Parkinson’s patient is imperative and also since he was being specialised during his entire admission there is absolutely no excuse for not trying to assist him with mobilising.
” 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 hand over medical instructions and recommendations
Wider context from the report “(7) Medical instructions and recommendations were not handed over. One example relates to instructions to clean Mr Lee’s infected eyes with saline every two hours to keep them open. This was not done and when he arrived at the Acute Hospital his eyes were crusted shut.
” 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 reasons for medication changes
Wider context from the report “(1) Mr Lee’s medication regimen which was to be the core of the admission was barely addressed and no reasons for any changes in medication appear in his 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 incorporate family information into falls risk assessment
Wider context from the report “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home . Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that.
” 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 assess mental capacity
Wider context from the report “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete.
” 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 completing Waterloo pressure-risk scoring
Wider context from the report “(4) No Waterloo score was done until the 4th May. Too late. No appropriate pressure relieving equipment was ordered until the 12th May. There was no evidence before me that the equipment was ever received or used for Mr Lee. When Mr Lee was admitted to the Acute Hospital he had a Grade 2 pressure sore on his Sacrum.
” 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 coherent, considered and reviewed care plan
Wider context from the report “(13) There was no coherent and carefully considered and reviewed Care Plan.
” 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 completing thromboprophylaxis assessment
Wider context from the report “(5) The thromboprophylaxis assessment which should have been carried out on either the 27th or 28th April was not done until the 6th May .
” 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 a timely bowel chart
Wider context from the report “(6) No bowel chart was kept until the 12th May. Why Why not? Even non nursing, non-medical professionals know that one of the several dangers of Parkinson’s Disease is constipation.
” 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 medication changes
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” 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 review nutritional risk after reduced eating
Wider context from the report “(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating .
There was no evidence of any reaction to Mr Lee’s substantial weight loss.
There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take 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 Failure to ensure timely provision and use of pressure-relieving equipment
Wider context from the report “(4) No Waterloo score was done until the 4th May. Too late. No appropriate pressure relieving equipment was ordered until the 12th May. There was no evidence before me that the equipment was ever received or used for Mr Lee. When Mr Lee was admitted to the Acute Hospital he had a Grade 2 pressure sore on his Sacrum.
” 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 care coordinator under the Care Programme Approach
Wider context from the report “(14) A Care Co-ordinator was not appointed , even though at the Inquest, it was confirmed that Mr Lee was being looked after on the Care Programme Approach (CPA).
The appointment of a Care Co-ordinator is at the heart of this framework and it was clear that such an appointment could have been helpful if not crucial in Mr Lee’s 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 Failure to regularly review original assessments
Wider context from the report “(12) As time went on there was no regular review of his original Assessments . This should have been done apparently by his Primary Nurse who carried out none of these functions and therefore her appointment for Mr Lee was irrelevant.
There should be a review of the role of Primary Nurse.
” 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 mental-capacity documentation at discharge
Wider context from the report “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete .
” 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 respond to substantial weight loss
Wider context from the report “(8) The MUST score was properly calculated on admission but not reviewed when it was clear he was not eating.
There was no evidence of any reaction to Mr Lee’s substantial weight loss.
There was no referral to dieticians. They just happened to attend a multi-disciplinary meeting on the 9th May (he was admitted on the 27th April and by the 9th May had lost 10 and ¾ pounds – 4.80 kilos). Re-weighing was requested by the dieticians. It did not take place.
” Open source report
9 Feb 2017 Matthew Christopher Roberts · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Failure to log and scrutinise faxes received by the Bognor EI team for missing pages and information View source Failure to clearly confirm the planned contact date with referrers View source Failure to undertake formal reviews of deaths of people known to the organisation View source Failure to seek and obtain final RCA reports from external organisations View source Failure to read referrer-provided written information before zoning and initial risk assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew Christopher Roberts · 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
Matthew Christopher Roberts, a music student with a history of psychosis and a previous intentional insulin overdose, took a large overdose of insulin and prescribed psychotropic medication after returning to Sussex. He was admitted to intensive care in a coma with significant hypoxic brain damage and later died from a major haemorrhage at the tracheostomy site caused by acute arteritis of the innominate artery. Concerns included failures to log and scrutinise referral faxes, consider written clinical and risk information before assessing urgency, confirm the date of first contact, and formally review the death and seek relevant learning.
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 log and scrutinise faxes received by the Bognor EI team for missing pages and information
Wider context from the report “(1) That there was no relevant policy, procedure or practice requiring faxes to the Bognor EI team be logged and scrutinised on receipt so that it might be noted if faxed pages were missing and potentially important information not received .
” 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 confirm the planned contact date with referrers
Wider context from the report “(3) That there was no relevant policy, procedure or practice whereby the Bognor EI team would clearly confirm with the referrer the date on which contact with a newly referred patient would be made .
” 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 undertake formal reviews of deaths of people known to the organisation
Wider context from the report “(4) That SPFT did not appear to have undertaken any formal review of the death of someone known to the organisation and, although SPFT were aware a RCA was being conducted by Avon and Wiltshire NHS Trust, SPFT had not received nor sought that final RCA report from Wiltshire. An opportunity to learn relevant lessons from the above events had therefore been delayed until the inquest, almost a year after events.
” 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 seek and obtain final RCA reports from external organisations
Wider context from the report “(4) That SPFT did not appear to have undertaken any formal review of the death of someone known to the organisation and, although SPFT were aware a RCA was being conducted by Avon and Wiltshire NHS Trust, SPFT had not received nor sought that final RCA report from Wiltshire . An opportunity to learn relevant lessons from the above events had therefore been delayed until the inquest, almost a year after events.
” 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 read referrer-provided written information before zoning and initial risk assessment
Wider context from the report “(2) That there was no policy, procedure or practice, requiring a member of the EI team to read written information provided by a referrer before the zoning meeting and initial risk assessment . Additionally it was practice, on occasions, for the information to be left unread until shortly before the first face to first appointment with the patient . Hence the determination of patient’s needs, the current level of risk and the urgency with which the first contact should be made with a patient was not informed by all the available information being fully considered.
” 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 Ensure 100% completion of Information Governance training among EIP staff.
Verbatim wording from the response “All Sussex Partnership NHS Foundation Trust staff must complete Information Governance training annually to ensure that information received and sent is managed safely and effectively. The training includes clear guidance on receiving and sending faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have completed this training within the last year. Following Mr Roberts’ inquest, the Senior EIP Management Team identified the need to supplement this training to ensure the Information Governance Principles were being followed by their staff. Therefore, the team designed and produced posters setting out the key guidance around the receipt of faxes. These are displayed above all fax equipment used by EIP staff.” Source location 2017-0028-Response-by-Sussex-Partnership-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 Implement the new Trust-wide Serious Incident Policy for timely investigations and learning.
Verbatim wording from the response “The Trust has developed a new Serious Incident Policy. Justine Rosser, Director of Nursing Standards and Safety is the lead for this new policy which I anticipate will be in use Trust wide from next week. This new policy will ensure investigations are carried out to identify learning without delay and follows NHS England guidelines and best practice. In future, when another Trust is leading on a Root Cause Analysis, SPFT will complete a local review and feed into the other Trust’s investigation to ensure maximum reflection and learning for both organisations is achieved.” Source location 2017-0028-Response-by-Sussex-Partnership-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 Complete a local review and contribute to another Trust’s investigation when that Trust leads a Root Cause Analysis.
Verbatim wording from the response “The Trust has developed a new Serious Incident Policy. Justine Rosser, Director of Nursing Standards and Safety is the lead for this new policy which I anticipate will be in use Trust wide from next week. This new policy will ensure investigations are carried out to identify learning without delay and follows NHS England guidelines and best practice. In future, when another Trust is leading on a Root Cause Analysis, SPFT will complete a local review and feed into the other Trust’s investigation to ensure maximum reflection and learning for both organisations is achieved.” Source location 2017-0028-Response-by-Sussex-Partnership-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 Display fax-handling guidance above EIP fax equipment.
Verbatim wording from the response “All Sussex Partnership NHS Foundation Trust staff must complete Information Governance training annually to ensure that information received and sent is managed safely and effectively. The training includes clear guidance on receiving and sending faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have completed this training within the last year. Following Mr Roberts’ inquest, the Senior EIP Management Team identified the need to supplement this training to ensure the Information Governance Principles were being followed by their staff. Therefore, the team designed and produced posters setting out the key guidance around the receipt of faxes. These are displayed above all fax equipment used by EIP staff.” Source location 2017-0028-Response-by-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 Finalize, approve, disseminate and embed shared EIP referral standards covering information review, risk assessment, contact planning and recordkeeping.
Verbatim wording from the response “The EIP Team Leaders and Senior Clinicians within the EIP service have reflected on this and have developed a clear set of shared standards for accepting referrals. Key elements of the standards are:” Source location 2017-0028-Response-by-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 service cannot always confirm the contact date at referral because appointments depend on risk assessment and patient choice.
Verbatim wording from the response “appointment times and venues for meetings. This helps the service to achieve higher rates of engagement with service users and better outcomes in relation to patient safety and service user recovery. Following a referral to the service, an EIP Practitioner will aim to make telephone contact with the referred client, based on their risk assessment, the next working day to agree a date and venue for their initial appointment. It is therefore not always possible to clarify at the point of referral, when the service user will be seen. I am pleased to say we achieved 95% in February 2017 for the new target for EIP access and waiting times for assessment and treatment to be within 14 days.” Source location 2017-0028-Response-by-Sussex-Partnership-NHS-Trust
Open published response
17 Feb 2016 Vanessa Christine DADSWELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of an intermediate urgent mental health referral timeframe View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Vanessa Christine DADSWELL · 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
Vanessa Dadswell died from injuries after placing herself in the path of an oncoming train at Whitley Railway Station on 2 April 2015. She had been urgently referred to Mental Health Services by her GP, requesting that she be seen within 24 hours, but she was not seen before her death. The principal concern was the lack of an intermediate referral option between four hours and within five days, and the absence of contact within the requested 24-hour period.
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 an intermediate urgent mental health referral timeframe
Wider context from the report “During the course of the inquest the evidence revealed that any urgent referral by a GP would be categorised by West Sussex Community Mental Health as either as a ‘4 hour’ referral or as a ‘within 5 day’ referral . A ‘4 hour’ referral would involve the service user having to attend A&E urgently for an assessment within 4 hours. A ‘within 5 day referral’ was exactly as described, an appointment within 5 days. The issue arose where a referring GP did not consider it necessary nor appropriate for a 4 hour referral and yet believed a 24 hour visit was necessary as 5 days would be too long . The deceased was not seen within 24 hours and committed suicide 3 days after the referral with no direct contact having been made. Evidence given by the Service manager for the Trust agreed that an intermediate option for referral would not be unreasonable .
Consideration should be given to an alternative, intermediate referral time between the current ‘4 hour’ and ‘within 5 day’ periods for referrals together with effective management thereof.
” 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 Enable Triage Team Leaders to book priority appointments directly.
Verbatim wording from the response “• Triage Team Leaders now have direct bookable Priority Appointment slots and do not need to pass priority referrals to the Assessment & Treatment Duty Worker for booking.” Source location Vanessa-DADSWELL-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.
Verbatim wording from the response “• Every morning the Triage Team Leader assesses all incoming referrals received out of hours and, if the referrer has requested the service user to be seen within 24 hours but did not consider a 4 hour response was clinically required, appointments within 24 hours are arranged.” Source location Vanessa-DADSWELL-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.
Verbatim wording from the response “Penny Fenton, General Manager Coastal West Sussex Care Delivery Service (CDS), Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden, Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly guide for staff. Dr Brian Solts, Divisional Clinical Director – Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell’s inquest, to the Adult Management Board to maximize learning and embed the improvements introduced.” Source location Vanessa-DADSWELL-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fast-track referrals to the first available appointment based on risk assessment.
Verbatim wording from the response “• Referrals can be fast track allocated by the Triage Team Leader so they do not wait up to 5 days for a slot; they are given the first available appointment, dependent on assessment of risk, often within 2–3 days.” Source location Vanessa-DADSWELL-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.
Verbatim wording from the response “The Service Specification for the Urgent Care Pathway detailing the 4 hour and 5 day referral options was developed in partnership with our West Sussex Commissioners and is due for renewal. Dr Solts has requested a meeting to be arranged with the West Sussex Mental Health commissioners to review the pathway jointly with us, in light of the improvements we have made, and the greater flexibility we have introduced, so it reflects current practice.” Source location Vanessa-DADSWELL-Response
Open published response
7 Jan 2016 Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Failure to communicate required discharge-assessment factors to the assessor View source Lack of a process for family members to provide views and information to early-discharge decision-makers View source Failure of assessment notes to clearly and accurately record information for the discharge decision-maker View source Lack of clarity about required coverage in discharge assessments View source Lack of a process for family members to understand the reasons for discharge View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joanne Michelle French (otherwise known as Joanne Michelle Hay) · 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
Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early discharge.
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 communicate required discharge-assessment factors to the assessor
Wider context from the report “(2) Factors that the person making the decision for early discharge required to be covered in the assessment process were not brought to the attention of the person who was to carry out that 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 Lack of a process for family members to provide views and information to early-discharge decision-makers
Wider context from the report “(4) Consent permitting, there was no process by which the unqualified family members who would be instrumental in caring for the discharged patient could input their views and/or information for those making the decision on early discharge and by which they could understand the reasons for 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 of assessment notes to clearly and accurately record information for the discharge decision-maker
Wider context from the report “(3) The assessment notes were not completely clear and accurate in recording the information to be provided to the person making the decision to 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 Lack of clarity about required coverage in discharge assessments
Wider context from the report “(1) When taking what was described as an ‘exceptional course’ in deciding to discharge the patient at an early stage, there was lack of clarity and understanding as to what the person making the decision to discharge required to be covered in the discharge assessment process .
” 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 process for family members to understand the reasons for discharge
Wider context from the report “(4) Consent permitting, there was no process by which the unqualified family members who would be instrumental in caring for the discharged patient could input their views and/or information for those making the decision on early discharge and by which they could understand the reasons for discharge .
” Open source report
6 Nov 2015 Mr Brian James SHILLINGLAW · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 7 Failure to implement the Observation Policy as part of risk assessment and management View source Failure to recognise, document and communicate Deprivation of Liberty Safeguarding Order status across care settings View source Failure to amend and dynamically update care plans and risk assessment documentation View source Failure to understand and comply with risk assessment and management policies View source Failure to ensure ongoing communication between members of the multi-disciplinary team View source Failure to create care plans, risk assessments and other admission documentation View source Failure to recognise patient status and record it correctly in all paperwork 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
Mr Brian James SHILLINGLAW · 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
The supplied text does not provide the circumstances or date of Mr Brian James SHILLINGLAW’s death. The principal concerns relate to the creation, updating and use of care plans and risk assessments, communication and coordination among staff, observation policy, and recording and communicating Deprivation of Liberty Safeguarding status.
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 implement the Observation Policy as part of risk assessment and management
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case.
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process . Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” 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, document and communicate Deprivation of Liberty Safeguarding Order status across care settings
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case.
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” 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 amend and dynamically update care plans and risk assessment documentation
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case.
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” 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 understand and comply with risk assessment and management policies
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case .
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” 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 ongoing communication between members of the multi-disciplinary team
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case.
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” 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 create care plans, risk assessments and other admission documentation
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case.
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” 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 patient status and record it correctly in all paperwork
Wider context from the report “(1) The creation of Care Plan, Risk Assessment and other admission documentation
(2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff
(3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw
(4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case.
(5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation
(6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork.
(7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust.
” Open source report
24 Jun 2015 Alice MEAD · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 5 Failure to review and update risk assessments View source Failure to document risk assessment reviews View source Failure to keep patients informed of Mental Health Service discussions View source Delays in responding to urgent concerns about known vulnerable patients View source Failure to replace and appoint a Care Co-ordinator View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alice MEAD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.
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 review and update risk assessments
Wider context from the report “(4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015 . If it was, such reviews should have been documented in accordance with the Care Programme Approach. They were not
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document risk assessment reviews
Wider context from the report “(4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015. If it was, such reviews should have been documented in accordance with the Care Programme Approach . They were not
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep patients informed of Mental Health Service discussions
Wider context from the report “(2) In spite of Alice calling the Brighton Urgent Response Service twice in December 2014 asking for a medication review and explaining she was not taking her mental health medications, no action was taken to keep her informed of discussions within the Mental Health Service . In particular her request for a medical review was discussed with her Consultant Psychiatrist and he apparently took the view that it was not necessary (poorly documented). Since there was no discussion with Alice , from her point of view, there was a lacuna in her care at a time when she was especially vulnerable, which lasted for several weeks.
” 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 responding to urgent concerns about known vulnerable patients
Wider context from the report “(3) Action, if it can be described as action, was only taken when Alice’s young son’s Heath Visitor wrote of her urgent concerns about Alice in good detailed e-mails sent to Alice’s GP and to the Community Mental Health Team on the evening of the 15ᵗʰ January. It was clear that the Mental Health Team should react . Their response was to phone Alice on the 16ᵗʰ and make an appointment to see her on the 28ᵗʰ January .
This “hands off” approach to a known vulnerable patient is unacceptable. The patient should be at the heart of Care Programme Approach care (indeed any care).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to replace and appoint a Care Co-ordinator
Wider context from the report “(1) When her Care Co-ordinator left the Trust she was not replaced so Alice was left without one of the corner stones of the Care Programme Approach. Although later a Multi-Disciplinary Team meeting decided she should have a Care Co-ordinator, no action was taken to appoint one .
” 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 Track risk-assessment dates in the East ATS caseload spreadsheet and monitor and audit compliance, escalating required action.
Verbatim wording from the response “Staff in the East ATS and MHRRS, responsible for assessing service users’ risk, have undergone bespoke Applied Suicide Intervention Skills Training (ASIST). This internationally renowned training was delivered in June 2015 by Grassroots, Suicide Prevention charity. To ensure risk assessments are up to date we have developed a new East ATS caseload spread sheet to capture risk assessment dates; supervisors will monitor this frequently, audit compliance, and escalate to the Team Leaders if action is required.” Source location 2015-0239-Response-by-Sussex-Partneraship-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 Provide a daily Duty Lead to prioritise incoming work, support call-taker decisions, and maintain team communication records.
Verbatim wording from the response “In relation to the calls Ms Mead made and communication with staff, Brighton Urgent Response Service, now called Mental Health Rapid Response Service (MHRRS), and the Assessment and Treatment Service (ATS) Duty Team are now co-located in the same working space. They have agreed a protocol for information sharing. This allows for improved communication between the teams and for vital information on service users to be shared with staff and fed back to service users. There is a communication book in place and a whiteboard to keep key pieces of information and service user contacts prominent within the team. In addition, to aid improved communication, there is now a Duty Lead working every day. The Duty Lead working that day prioritises the incoming work and supports the decisions made by the call takers. They review and update the communication book and whiteboard.” Source location 2015-0239-Response-by-Sussex-Partneraship-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 Introduce face-to-face assessment for East ATS service users making three calls within two weeks, subject to senior clinical review and documented rationale for exceptions.
Verbatim wording from the response “Following Ms Mead’s request, a new approach to calls is underway in East ATS. If a service user calls 3 times in a 2 week period in need of mental health input, they will be seen face to face. The only exceptions will be in circumstances when the case is reviewed by a senior member of the team and a face to face appointment is not deemed in the best interests of the service user or appropriate; in these cases a detailed record will be kept documenting the decision rationale.” Source location 2015-0239-Response-by-Sussex-Partneraship-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 Implement multidisciplinary caseload reviews, prioritising reviews when care coordinators leave and documenting decisions in electronic records.
Verbatim wording from the response “As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. ████████ General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team.” Source location 2015-0239-Response-by-Sussex-Partneraship-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 Review and redesign Trust-wide Care Programme Approach processes, including developing the new policy and preparing for electronic-record rollout.
Verbatim wording from the response “The Care Programme Approach (CPA) is in the process of being reviewed across the Trust. This work is being led by ████████, Director of Occupational Therapy and Recovery Practice. We have a newly constituted CPA steering group, with cross care group representation and we are agreeing the new processes in preparation for the roll out of Carenotes (the new electronic records system). A new CPA policy has been drafted and we hope to launch it in September 2015. When the new CPA policy is launched there will be full staff training in place. Information leaflets and short films will be available and all information will be available on the Trust’s intranet. The training will be co-produced with service users and peer trainers to ensure a holistic approach.” Source location 2015-0239-Response-by-Sussex-Partneraship-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 Allocate service users a lead practitioner or care coordinator according to clinical need.
Verbatim wording from the response “As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. ████████ General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team.” Source location 2015-0239-Response-by-Sussex-Partneraship-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 Co-locate urgent-response and assessment teams and establish an information-sharing protocol and shared communication tools.
Verbatim wording from the response “In relation to the calls Ms Mead made and communication with staff, Brighton Urgent Response Service, now called Mental Health Rapid Response Service (MHRRS), and the Assessment and Treatment Service (ATS) Duty Team are now co-located in the same working space. They have agreed a protocol for information sharing. This allows for improved communication between the teams and for vital information on service users to be shared with staff and fed back to service users. There is a communication book in place and a whiteboard to keep key pieces of information and service user contacts prominent within the team. In addition, to aid improved communication, there is now a Duty Lead working every day. The Duty Lead working that day prioritises the incoming work and supports the decisions made by the call takers. They review and update the communication book and whiteboard.” Source location 2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
Open published response
21 Apr 2015 Bruce LONGDEN · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 7 Failure to conduct observations and therapeutic engagement in accordance with policy View source Failure of the Mental Health Team to adhere to commonly understood terminology View source Delays in reporting an absconsion to Sussex Police View source Failure to understand terminology used by the mental health liaison team View source Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust View source Failure to follow protocols for transferring Sussex Partnership Trust patients to the acute hospital View source Failure to appreciate the significance of a patient’s mental health condition 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
Bruce LONGDEN · 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
Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.
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 conduct observations and therapeutic engagement in accordance with policy
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 Mental Health Team to adhere to commonly understood terminology
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 reporting an absconsion to Sussex Police
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 understand terminology used by the mental health liaison team
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 protocols for transferring Sussex Partnership Trust patients to the acute hospital
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 appreciate the significance of a patient’s mental health condition
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” Open source report
5 Dec 2014 Paul Leslie HYDE · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 6 Delays in appropriately addressing referrals within the 28-day period View source Failure to contact the GP about the referral View source Poor documentation of referral-management decisions View source Failure to provide face-to-face psychiatric medication reviews View source Lack of a referral follow-up system View source Lack of a facility for psychiatrists to participate in assessment and determine a course of treatment 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
Paul Leslie HYDE · 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 Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.
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 appropriately addressing referrals within the 28-day period
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the GP about the referral
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor documentation of referral-management decisions
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face psychiatric medication reviews
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a referral follow-up system
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a facility for psychiatrists to participate in assessment and determine a course of treatment
Wider context from the report “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety.
(2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient.
(3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde.
It should have been obvious from the start that this was not a direction for this referral to take.
There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be.
In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up.
(4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose.
In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death.
” 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 clinical triage meetings through Consultant Psychiatrist, lead nurse, administrator and additional specialist participation.
Verbatim wording from the response “████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.” Source location 2014-0527-Response-by-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 Recruit an additional triage administrator.
Verbatim wording from the response “████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.” Source location 2014-0527-Response-by-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 Allocate named Consultant Psychiatrists to GPs and arrange meetings to clarify referral roles and expectations.
Verbatim wording from the response “We are always striving to improve the interface between primary care and secondary mental health services. In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists. Meetings between the psychiatrists and GPs have been arranged. ████████ is leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals. Work is on-going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement. Mr Hyde’s experience has been shared (anonymously) with staff to drive home the lessons to be learned. In addition, to ensure widespread learning, feedback from the case has been given to ████████ Director of Nursing Standards and Safety.” Source location 2014-0527-Response-by-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 Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
Verbatim wording from the response “The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.” Source location 2014-0527-Response-by-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 Review administration triage processes to reduce triage waiting times.
Verbatim wording from the response “████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.” Source location 2014-0527-Response-by-Sussex-Partnership-NHS
Open published response
29 Apr 2014 Janet BLACKMAN · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to apply DVT avoidance policy to patients in psychiatric units View source Failure to provide seamless physical and mental healthcare including DVT prophylaxis within a single unit View source Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units View source Failure of psychiatric units to deliver required physical healthcare 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 BLACKMAN · 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 Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.
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 apply DVT avoidance policy to patients in psychiatric units
Wider context from the report “(3) By way of emphasis and duplication, that if anything, the NICE recommendations and policy for DVT avoidance is as relevant to patients being treated in psychiatric units as in any other units providing patient care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide seamless physical and mental healthcare including DVT prophylaxis within a single unit
Wider context from the report “(4) It should be possible to develop a system enabling a seamless delivery of care covering both the physical and mental health treatment including DVT Prophylaxis to a patient in a single unit without the need to move patients physically from one unit to another , even if different aspects of care are delivered by different trusts.
” 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 apply DVT prophylaxis policy and clerking to patients entering psychiatric units
Wider context from the report “(2) It would seem that the logic of the DVT prophylactic policy as recommended by NICE is not applied to those patients coming into the psychiatric units – or if it were then Mrs Blackman would have been subject to the same clerking process on each of her admissions to the HKU and thereafter would have been able to receive the prophylaxis care that had been prescribed for her in the AMU.
” 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 psychiatric units to deliver required physical healthcare
Wider context from the report “(1) The HKU like other units dedicated to the delivery of essentially psychiatric care are not able to deliver at least some of the elements required of the patient for her physical healthcare .
” Open source report
3 Apr 2014 DANUTA Bronislawa CORBETT · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 3 Failure to allocate an appropriately familiar escort for informal patient leave View source Failure to hand over relevant patient and suicide-risk information to the leave escort View source Failure to document leave reasons, risk assessments and decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DANUTA Bronislawa CORBETT · 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
Danuta Bronislawa Corbett jumped from the window of her eighth-floor flat during escorted leave on 4 November 2013 and died. The report raises concerns that decisions about her leave were not documented in accordance with policy and that the agency escort was not given important information about her distress, her home, or her stated threat to kill herself by jumping from it.
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 allocate an appropriately familiar escort for informal patient leave
Wider context from the report “(1) The report concerns the leave policy so far as it relates to Informal Patients.
(Copy enclosed – refer to S. 4.5 and then S. 43).
(2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed.
No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented.
On the 4th she has another Ward Review. She remained on 15 minute observations.
As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November.
In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home.
She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before.
No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort.
Thus none of the decisions regarding her Leave on the 4th November are documented.
This patient jumped out of her 8th floor flat window at home during this escorted leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over relevant patient and suicide-risk information to the leave escort
Wider context from the report “(1) The report concerns the leave policy so far as it relates to Informal Patients.
(Copy enclosed – refer to S. 4.5 and then S. 43).
(2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed.
No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented.
On the 4th she has another Ward Review. She remained on 15 minute observations.
As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November.
In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home.
She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before.
No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort , in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort.
Thus none of the decisions regarding her Leave on the 4th November are documented.
This patient jumped out of her 8th floor flat window at home during this escorted leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document leave reasons, risk assessments and decisions
Wider context from the report “(1) The report concerns the leave policy so far as it relates to Informal Patients.
(Copy enclosed – refer to S. 4.5 and then S. 43).
(2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed.
No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented.
On the 4th she has another Ward Review. She remained on 15 minute observations.
As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November.
In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home.
She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before.
No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort.
Thus none of the decisions regarding her Leave on the 4th November are documented.
This patient jumped out of her 8th floor flat window at home during this escorted leave.
” 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 Ensure proper handovers with agency nurses accompanying patients.
Verbatim wording from the response “Finally, it is clear that the communication with the agency nurse who was accompanying Danuta should have been much better. The nurse responsible acknowledges this and will always ensure proper handovers take place in the future.” Source location 2014-0150-Response-by-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 shortcomings identified were unlikely to have prevented the tragic outcome.
Verbatim wording from the response “It seems unlikely that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome. However, all the staff involved in Danuta’s care have carefully reflected on what happened and used the learning to improve their practice.” Source location 2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Open published response
31 Jan 2014 Ryan Chapman · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 9 Delays in completing health care plans View source Lack of written information for families on patient admission View source Delays in completing risk assessments View source Failure to provide families with copies of patients’ care plans View source Lack of consistent visitor sign-in and recording on the ward View source Failure to carry out the required assessment when patients leave the ward View source Unclear application of the leave policy to patients attending activities within hospital grounds View source Lack of staff understanding of the leave policy for non-detained patients View source Unclear role of Peer Support workers as escorts for patients leaving the ward View source See 6 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
Ryan 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
Ryan Chapman was admitted to a mental health ward and, while being accompanied to an activity, left the hospital and ran into the path of an articulated lorry. He died from his injuries on 22 May 2013. Concerns included staff misunderstanding and inconsistent application of the Trust’s leave policy, uncertainty about the role of peer support workers as escorts, delays in completing his risk assessment and care plan, limited information for his family, and inconsistent ward visitor security.
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 completing health care plans
Wider context from the report “4. Ryan’s Risk assessment and Health Care Plan was not completed within the required period . This plan was completed two days after it should have been .
” 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 written information for families on patient admission
Wider context from the report “5. There was lack of written information provided to families by the Hospital on admission to the patient . In addition the family were not provided with a copy of the Ryan’s care plan.
” 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 completing risk assessments
Wider context from the report “4. Ryan’s Risk assessment and Health Care Plan was not completed within the required period . This plan was completed two days after it should have been.
” 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 families with copies of patients’ care plans
Wider context from the report “5. There was lack of written information provided to families by the Hospital on admission to the patient. In addition the family were not provided with a copy of the Ryan’s care plan .
” 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 consistent visitor sign-in and recording on the ward
Wider context from the report “6. There appeared to be a general lack of security on ward with regards to visitors . There was no consistent signing in procedure and family members could be on the ward without there being a record being kept .
” 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 the required assessment when patients leave the ward
Wider context from the report “2. Staff seemed unclear as whether or not this policy should be applied when patients left the ward to attend activities within the hospital grounds. It if was to be applied then it was not strictly adhered to in Ryan’s case. The Nurse in Charge did not carry out an assessment, as required under Para 4.5., of Ryan at the time he left 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 Unclear application of the leave policy to patients attending activities within hospital grounds
Wider context from the report “2. Staff seemed unclear as whether or not this policy should be applied when patients left the ward to attend activities within the hospital grounds . It if was to be applied then it was not strictly adhered to in Ryan’s case. The Nurse in Charge did not carry out an assessment, as required under Para 4.5., of Ryan at the time he left 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 staff understanding of the leave policy for non-detained patients
Wider context from the report “1. During the course of the evidence it was shown that there a lack of understanding by staff of the Trust’s Leave for Non detained patients Policy .
” 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 role of Peer Support workers as escorts for patients leaving the ward
Wider context from the report “3. Staff appeared to be unclear as to the role of a Peer Support worker with regards to whether or not they were able to fulfil the role of an escort for patients leaving the ward . The Peer support worker who gave evidence indicated that she did not consider herself an escort but she was a responsible adult who accompanied patients. In Ryan’s case the Doctor had approved his leave only when accompanied by an escort. The terminology used in the policy causes this confusion.
” Open source report
27 Jan 2014 Maureen Leaver · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 3 Lack of effective systems to investigate, diagnose and manage acutely ill elderly patients with complex psychosis and associated dementia View source Lack of understanding of legal duties when transferring non-consenting patients from Section 4 MHA 1983 to informal patient status View source Lack of medical supervision of in-patients 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
Maureen Leaver · 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
Maureen Leaver, who had dementia and severe delusions, was admitted for assessment in July 2010 and later transferred to hospital with profound hypothermia. She died on 6 October 2010; the report identified concerns about inadequate medical supervision and systems for investigating and managing acutely ill elderly patients, as well as understanding of legal duties when changing her patient status.
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 effective systems to investigate, diagnose and manage acutely ill elderly patients with complex psychosis and associated dementia
Wider context from the report “1. The lack of medical supervision of in-patients in Grove Ward, Harold Kidd Unit and the lack of effective systems to investigate, diagnose and manage acutely ill elderly patients suffering from complex psychosis and associated dementia
” 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 understanding of legal duties when transferring non-consenting patients from Section 4 MHA 1983 to informal patient status
Wider context from the report “2. A lack of understanding of the legal duties imposed by the Mental Health Act 1983 and the Mental capacity Act 2005 when transferring patients who cannot consent to treatment from Section 4 MHA 1983 to being an informal patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical supervision of in-patients
Wider context from the report “1. The lack of medical supervision of in-patients in Grove Ward, Harold Kidd Unit and the lack of effective systems to investigate, diagnose and manage acutely ill elderly patients suffering from complex psychosis and associated dementia
” Open source report
21 Aug 2013 Mr Walker · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Scalable fences surrounding ward external common areas View source Failure to document the rationale and risk factors underlying changes in observation levels View source Failure to communicate risk-care-planning issues among all MDT members View source Failure to align observation levels with changing suicidal risk View source Failure to revisit and revise risk care plans View source Delays in declaring an AWOL patient missing and informing the police View source Insufficient scope and depth of risk care planning 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
Mr Walker · 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
Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.
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 Scalable fences surrounding ward external common areas
Wider context from the report “(4) At the time of the incident the fences surrounding the external common areas of the ward were of a scalable height by any patient determined enough to do so . It is accepted that this has been subsequently addressed.
” 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 document the rationale and risk factors underlying changes in observation levels
Wider context from the report “(2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts in the week before his death), without explanation, remains of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate risk-care-planning issues among all MDT members
Wider context from the report “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT , this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised.
” 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 align observation levels with changing suicidal risk
Wider context from the report “(2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts in the week before his death ), without explanation, remains of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to revisit and revise risk care plans
Wider context from the report “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised.
” 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 declaring an AWOL patient missing and informing the police
Wider context from the report “(3) Whilst it was accepted in evidence that the hospital's AWOL policy was robust and activated and implemented appropriately, concern was raised by the family with regard to the length of time taken before Mr Walker could be declared missing and the police informed .
” 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 scope and depth of risk care planning
Wider context from the report “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised.
” 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 Complete regular audits of risk-care-planning documentation to ensure required standards are met.
Verbatim wording from the response “The point I think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree. As I say, the Risk Care Plan for Mr Walker was poor. In recognition of the importance of documentation and to ensure continued learning and improvement, we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Alter hospital fences to make them more difficult to climb over while keeping garden doors open.
Verbatim wording from the response “4. Fences
Opal Ward at Langley Green Hospital is an open ward and so there is no requirement to have fences at a particular height, as would be the case for a secure unit. Had Mr Walker or any other patient at that time been considered a risk of absconding then staff would have taken steps to ensure appropriate supervision; this may have included locking the door to the garden. As you know, the fences throughout Langley Green Hospital have been subsequently altered to make it much more difficult to get over. This was done in order to make it possible to always keep the doors to the garden open, as this promotes a more therapeutic environment. Absconding in the way Mr Walker did we believe was not foreseeable, for the reasons already set out.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise clinical risk-care-planning documents to reduce repetition and support succinct recording of relevant issues.
Verbatim wording from the response “The point I think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree. As I say, the Risk Care Plan for Mr Walker was poor. In recognition of the importance of documentation and to ensure continued learning and improvement, we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide staff training on consistently documenting the rationale for changes in observation levels.
Verbatim wording from the response “2. Documented rationale for the observation level
We acknowledge that the rationale for changing the level of observation was not documented. The expectation is that this must be written down and this is what is stated in the policy. This is very important and our Nurse Consultant has provided training to staff to help ensure this happens more consistently.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians understood the patient’s risks despite deficiencies in some risk-care documentation.
Verbatim wording from the response “1. Risk care planning
It is difficult to respond definitively to your conclusion that the consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient. We do acknowledge that some documentation was not of the standard we would expect. In particular, the Risk Care Plan and the Formulation section of the MDT Clinical Review was poor and so taking this in isolation could imply ████████ risk care planning. However, I think it is important to reinforce the evidence of Consultant Psychiatrist. She explained that the staff caring for Mr Walker did have a good understanding of his risks and that these risks were documented in the Acute Care Risk Assessment, Acute Care Screening and the daily MDT Evaluation and Progress Notes.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The AWOL policy was implemented appropriately, including searching and contacting police after the patient was found missing.
Verbatim wording from the response “3. AWOL
Staff contacted the Police within 50 minutes of them noticing that Mr Walker was missing. This was after a full search of the ward, hospital, and hospital grounds was conducted, and after attempts were made to contact Mr Walker and his family. It was also the conclusion from our internal investigation that the AWOL policy was implemented appropriately.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Observation rationale need not be recorded when levels remain unchanged unless clinical staff identify a significant risk change.
Verbatim wording from the response “The point you make about the absence of documented rationale when observation levels do not change is a slightly different issue. Firstly, the use of observation to provide support and to manage risk is something clinicians consider constantly, and so we would not always expect the rationale to be recorded during periods when the level remains the same. This would only be necessary when there is a significant change in risk, as determined by clinical staff.” Source location 2013-0213-Response-by-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 An open ward does not require secure-unit-height fencing; supervision would be increased if staff identified an absconding risk.
Verbatim wording from the response “4. Fences
Opal Ward at Langley Green Hospital is an open ward and so there is no requirement to have fences at a particular height, as would be the case for a secure unit. Had Mr Walker or any other patient at that time been considered a risk of absconding then staff would have taken steps to ensure appropriate supervision; this may have included locking the door to the garden. As you know, the fences throughout Langley Green Hospital have been subsequently altered to make it much more difficult to get over. This was done in order to make it possible to always keep the doors to the garden open, as this promotes a more therapeutic environment. Absconding in the way Mr Walker did we believe was not foreseeable, for the reasons already set out.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians did not consider a different observation level clinically indicated based on information available at the time.
Verbatim wording from the response “Reflecting on the information available to them at the time, the clinicians involved do not believe a different level of observation was clinically indicated.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient’s manner of absconding was not foreseeable based on the information available to staff.
Verbatim wording from the response “4. Fences
Opal Ward at Langley Green Hospital is an open ward and so there is no requirement to have fences at a particular height, as would be the case for a secure unit. Had Mr Walker or any other patient at that time been considered a risk of absconding then staff would have taken steps to ensure appropriate supervision; this may have included locking the door to the garden. As you know, the fences throughout Langley Green Hospital have been subsequently altered to make it much more difficult to get over. This was done in order to make it possible to always keep the doors to the garden open, as this promotes a more therapeutic environment. Absconding in the way Mr Walker did we believe was not foreseeable, for the reasons already set out.” Source location 2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations