Concerns raised 1 Failure of the section 17 leave policy to reference the new leave processes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hilary Jane 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
Hilary Jane Chapman, who was detained under section 3 at Lanchester Road Hospital, left on unescorted leave and was later found unconscious in her car after a suspected overdose. She suffered cardiac arrest and hypoxic brain injury, received palliative care, and died at St Cuthbert’s Hospice on 11 March 2025. The principal concern was that the Trust’s updated section 17 leave processes were not reflected in its overarching policy, including issues concerning communication of leave arrangements to relevant people.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the section 17 leave policy to reference the new leave processes
Wider context from the report “Tees, Esk and Wear Valley NHS Foundation Trust ("the Trust") gave evidence of policy changes to the way in which section 17 leave was prescribed and also how families were informed and updated of such prescribed leave. The Trust explained the new processes as involving the discussion and agreement of a "Leave Plan" based on the completion of a "Leave Discussion Form" which documents the discussions which have taken place and the terms and conditions of any prescribe leave, with the "Leave Plan" being shared with any person involved in the patient's supervision whilst on leave.
Whilst improvements by the Trust to the way in which section 17 leave is discussed, prescribed and agreed are acknowledged and welcomed and whilst I acknowledge what I was told about staff training having been undertaken in respect of the new processes, I was concerned that the overarching and updated section 17 leave policy makes no reference to these new processes . I was told that a review of the policy was contemplated although not likely before September 2026. I am concerned at this evidenced gap in Trust policy .
” 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 Amend the Section 17 leave policy to direct staff to PIPA procedures, leave-risk documentation and electronic-care-record leave-plan procedures.
Verbatim wording from the response “In order to address these identified changes, as of April 3rd 2026 we have amended the Section 17 policy to direct staff to PIPA (Purposeful In - Patient Admission) procedures and standard processes. This directs adult acute admission ward staff to the relevant documentation required to ensure the above. This includes the,” Source location 2026-0111 - Response from Tees, Esk and Wear Valleys 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 Conduct a full stakeholder review of the Section 17 Leave Policy, including people with lived experience and carers.
Verbatim wording from the response “On receipt of the PFD, the Trust's Chief Nurse and Medical Director commissioned a working group consisting of; the Trust's Care Group Director of Nursing, Deputy Care Group Director of Nursing, Associate Medical Director, Associate Director of Nursing for Urgent Care and the Deputy Head of Mental Health Legislation, to review the current Section17 Leave Policy in relation to the specific concerns that were raised. A full review of the Section17 Leave Policy is planned for early June 2026 which will involve all stakeholders, including those with lived experience of receiving services and of caring for those who receive services.” Source location 2026-0111 - Response from Tees, Esk and Wear Valleys NHS Trust
Open published response
5 Sep 2025 Victoria Anne TAYLOR · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 5 Failure to coordinate multi-agency consideration of appropriate support View source Failure to offer or consider trauma treatment pathways through secondary mental health services View source Failure to explain the rationale, provision and NHS alternatives for a private psychotherapy referral View source Failure to provide an effective alternative when a referred provider does not respond View source Failure of safety plans to provide additional support responsive to identified needs 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
Victoria Anne TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate multi-agency consideration of appropriate support
Wider context from the report “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to offer or consider trauma treatment pathways through secondary mental health services
Wider context from the report “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her . The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her . Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain the rationale, provision and NHS alternatives for a private psychotherapy referral
Wider context from the report “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT . When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an effective alternative when a referred provider does not respond
Wider context from the report “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again . Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of safety plans to provide additional support responsive to identified needs
Wider context from the report “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service . The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.
” Open source report
28 May 2025 Mr Dean Bradley · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 2 Failure to provide adequate safeguarding for intoxicated people before mental health assessment View source Insufficient resources for safeguarding people with mental health illnesses whilst intoxicated View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Dean Bradley · 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 Dean Bradley was found deceased by hanging in his hostel flat on 15 October 2021, after earlier suicidal behaviour and expressions of paranoid and persecutory beliefs while apparently under the influence of drugs. Concerns included whether current resources adequately safeguard people with mental health concerns while intoxicated, and failures to contact mental health services and to relay the details of his crisis to hostel staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate safeguarding for intoxicated people before mental health assessment
Wider context from the report “2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for safeguarding people with mental health illnesses whilst intoxicated
Wider context from the report “1) Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the report’s learning and reiterate relevant best practice with police and Crisis Teams.
Verbatim wording from the response “Organisational Learning
The Trust host regular Multi-Agency Mental Health Legislation Operational Groups where partner agencies and organisations, including the police, meet to discuss operational issues and to try to resolve issues that may have arisen and to identify areas of best practice. We have shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025. This enabled us to ensure that the police are aware of the Report and the issues of concern that you have raised and to identify and re-iterate best practice in this, or any similar, scenarios. This report has also been shared with Crisis Teams.” Source location Response from Tees Esk and Wear Valley NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing health-based places of safety enable police to safeguard and assess intoxicated people under Section 136 where no suspected physical risk.
Verbatim wording from the response “Within TEWV we provide health-based places of safety (HBPOS) across the Trust including in Middlesbrough, and we did so at the time of this incident. These are used by the police to bring people they have concerns about under Section 136 of the Mental Health Act (MHA) 1983 to enable assessment by appropriately trained Mental Health Professionals. This would be the case even if the person is intoxicated or under the influence of substances but with no suspected physical risk.” Source location Response from Tees Esk and Wear Valley NHS
Open published response
14 Oct 2024 Stephen Frederick DULLING · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 10 Failure to assess and escalate refusal of intravenous fluids View source Failure to establish whether an assessed risk of harm had increased and required emergency intervention View source Failure to explain anticipated police assistance View source Failure to provide practical emergency-care advice to carers View source Failure to ensure the recorded and implemented diet reflects identified nutritional needs View source Delays in undertaking and completing patient safety investigation reviews View source Delayed nursing response to information about choking View source Failure to implement and maintain food charts after malnutrition risk assessment View source Failure to make direct nutritional-needs inquiries of the primary carer View source Failure to debrief choking-incident staff within 72 hours View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Frederick DULLING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and escalate refusal of intravenous fluids
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids ;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether an assessed risk of harm had increased and required emergency intervention
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered , nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain anticipated police assistance
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police .
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide practical emergency-care advice to carers
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance , nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the recorded and implemented diet reflects identified nutritional needs
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above ;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking and completing patient safety investigation reviews
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review , resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed nursing response to information about choking
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking ;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and maintain food charts after malnutrition risk assessment
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment ;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct nutritional-needs inquiries of the primary carer
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs , despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to debrief choking-incident staff within 72 hours
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event . This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 Present the case to the Trust Urgent Care Board to address learning from the incident.
Verbatim wording from the response “I am sorry to hear that the role and rationale for contacting the Police was not clearly communicated to Mr Dulling's wife. The case will be presented at the Trust Urgent Care Board which takes place on the 23 January 2025. Learning from this incident will also be shared at the all the Trust's Specialty Clinical Networks meetings on 19 December 2024, 20 December 2024, 7 January 2025 and 22 January 2025 via the service development managers for adult mental health, mental health services for older people, child and adolescent mental health services and adult learning disabilities to highlight the importance of clear communication and the impact of it and to the Trustwide Organisational Learning Group on 5 December 2024.” Source location Response from Tees Esk and Wear Valley 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 Share incident learning across Trust clinical networks and the Organisational Learning Group to reinforce clear communication about contacting police.
Verbatim wording from the response “I am sorry to hear that the role and rationale for contacting the Police was not clearly communicated to Mr Dulling's wife. The case will be presented at the Trust Urgent Care Board which takes place on the 23 January 2025. Learning from this incident will also be shared at the all the Trust's Specialty Clinical Networks meetings on 19 December 2024, 20 December 2024, 7 January 2025 and 22 January 2025 via the service development managers for adult mental health, mental health services for older people, child and adolescent mental health services and adult learning disabilities to highlight the importance of clear communication and the impact of it and to the Trustwide Organisational Learning Group on 5 December 2024.” Source location Response from Tees Esk and Wear Valley 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 Police advice was correct because violence and aggression required an emergency response with police powers, rather than Crisis Team intervention alone.
Verbatim wording from the response “The Crisis Team are not an emergency service and when there is felt to be an immediate and significant risk, the correct advice is for the emergency services to be contacted, which depending upon the nature of the call will either be done by the person contacting emergency services themselves or the Crisis Team agreeing to contact on their behalf. This will then result in a decision being made by the emergency services as to whether there will be a response from the Police or Ambulance Service.” Source location Response from Tees Esk and Wear Valley NHS Foundation Trust
Open published response
Concerns raised 3 Failure to inform accompanying carers of section 17 leave conditions View source Removal of the requirement for accompanying persons to sign section 17 leave forms View source Failure to provide section 17 leave forms to accompanying carers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew Clive GALE · 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 Clive Gale died on 19 March 2023 after being detained under the Mental Health Act and granted Section 17 leave. The conditions of his leave, including that he should not be left alone, were not properly recorded or communicated to his family. The report raised concern about inconsistent compliance with providing Section 17 leave forms and the removal of a requirement for the accompanying person to sign the form, creating a risk of future deaths.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform accompanying carers of section 17 leave conditions
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form.
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system.
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Removal of the requirement for accompanying persons to sign section 17 leave forms
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form.
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient , the explanation for this being the Trust's roll-out of a new digitised system .
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide section 17 leave forms to accompanying carers
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form .
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her . The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave . That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024 , with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system.
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, amend, approve and roll out the Section 17 leave policy, including signed leave documentation, accompanying-person confirmation and ward-held copies.
Verbatim wording from the response “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue auditing clinical records to assess compliance with Section 17 leave procedures.
Verbatim wording from the response “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.” Source location Response from Tees Esk and Wear Valleys 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 Assess the impact of the amended Section 17 leave policy changes.
Verbatim wording from the response “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Section 17 leave folders, flowcharts, templates and contact cards to give staff, patients and accompanying persons accessible leave requirements and contact information.
Verbatim wording from the response “In order to further assist staff with the requirements of Section 17 leave, staff have been provided with leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At the front of the leave folders a flowchart that has been produced to remind staff of the requirements of Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given to the patient and the accompanying person, which have details of the ward contact details, any conditions of leave, a check that a copy of the section 17 leave form has been provided and details of time and date which patient is due to return.” Source location Response from Tees Esk and Wear Valleys 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 Include Section 17 leave and accompanying-role responsibilities in mandatory Trust-wide preceptorship for newly joining registered nurses.
Verbatim wording from the response “As previously advised, following the May 2024 audit results the Trust implemented the following to improve Section 17 leave requirements:” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver targeted Section 17 leave training to Associate Directors of Nursing and Quality.
Verbatim wording from the response “The Associate Director of Nursing and Quality has developed and delivered targeted training to all Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and procedures and the need to ensure that processes are being followed and documented. This training is currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section 17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to temporary workers, community staff, corporate services, and professional groups to ensure they are aware of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the Trust captures all relevant staff.” Source location Response from Tees Esk and Wear Valleys 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 Section 17 leave and monitoring forms will remain in paper format rather than being converted to electronic forms.
Verbatim wording from the response “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
Concerns raised 5 Failure of acute, alcohol and drug treatment, and mental health teams to share crucial risk information appropriately View source Failure to ensure a robust safety plan upon discharge View source Failure of acute and mental health teams to consider contacting family or friends as an informal safety net View source Failure to determine whether discharge or step-down should be delayed until a place of safety is identified View source Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug 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
Andrew James Naylor · 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
Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of acute, alcohol and drug treatment, and mental health teams to share crucial risk information appropriately
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams , to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records ), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a robust safety plan upon discharge
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of acute and mental health teams to consider contacting family or friends as an informal safety net
Wider context from the report “(3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends , which may have provided an essential safety net in the absence of accessible professional support . The TEWV Trust are candid that work in relation to this issue is a work in progress and remains 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether discharge or step-down should be delayed until a place of safety is identified
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge , and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records), and whether discharge should be delayed or care stepped down, until a place of safety is identified , and to ensure that a robust safety plan is in place upon 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug
Wider context from the report “(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug ████████ should they drink alcohol or misuse drugs.
” 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 Test and roll out CDDFT electronic patient-record access on TEWV clinicians’ laptops for joined-up assessments and information sharing.
Verbatim wording from the response “advised, the EPR team within CDDFT attended the liaison team office on Wednesday 27 March 2024 to take steps to begin the process of putting the acute Trust's EPR on to the TEWV clinician's laptops. The EPR team have assisted, a data protection impact assessment was completed however we then experienced issues with organisational firewalls. The two IT teams have been working together to resolve this and we are now testing the platform. The testing concludes 06/08/24 and if it has been successful, it will be rolled out further from 12/08/24.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use bereaved-family lived experience to identify organisational and service-level practice changes and related training, process, environment and culture goals.
Verbatim wording from the response “3. Sharing lived experience:
A bereaved family were recently invited to speak to Trust staff at the Trust Fundamental Standards Group about their lived experience particularly around the importance of communicating effectively with families and carers of those experiencing mental illness, to offer staff an incredibly useful insight from their perspective. Attendees at the meeting worked with the family to identify impactful ways to share their experience further, and to identify practice changes that could be made organisationally and at service level. The group sought to identify short, medium and long term goals relating to training, process, environment and culture, working with the family to consider impactful changes to service delivery. We committed to identifying the priority actions and identify leads to take those actions forwards.” Source location Response from Tees, Esk and Wear Valleys 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 Create updated common-sense confidentiality guidance to help staff communicate more effectively with families and carers.
Verbatim wording from the response “2. Common sense confidentiality guidance:
The Associate Directors and Associate Nursing Directors have met to discuss and review the Trust's current common sense confidentiality guidance leaflet, it will be consistent with the open letter to staff. This has included a review of the guidance issued by other Trusts on this matter. As a result, an updated guidance leaflet is being created to assist staff in better communicating with families and carers.” Source location Response from Tees, Esk and Wear Valleys 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 Reissue an open letter to all staff supporting appropriate information sharing while balancing patient confidentiality and safety.
Verbatim wording from the response “1. Open letter to all staff:
On 13 May 2024, I personally reissued a letter (initially sent in June 2021) to all Trust staff members about the support the Trust will offer when making decisions about the difficult balance between patient confidentiality and appropriate sharing of information. In particular, the letter provides “We want to emphasise however to you all, that we would rather support you for saving a person's life by breaching their confidentiality than have to explain why we held onto information that could have made a difference.” I understand that you have already received a copy of this open letter.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue training and induction processes to improve communication with families and carers.
Verbatim wording from the response “will never be 'complete', as the Trust will always be striving to improve communication with carers, and we will continually reflect, learn and improve, as well as continuing training and processes of induction for those joining the organisation. This will not have an end date but as previously advised, the current initiatives to improve Trust processes are:” Source location Response from Tees, Esk and Wear Valleys 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 Audit and deep-dive liaison documentation to verify that verbal handovers to other Trusts and services are recorded, addressing issues through supervision and team meetings.
Verbatim wording from the response “3. Audits:
I can reiterate that in order to provide a check that improvements are being made in respect of communicating with acute Trust staff, a further check has been added when completing the team's monthly audit to ensure it is documented that a verbal handover has been completed. This check is completed alongside the Trust Quality Assurance Schedule audit (a Trust standard) and the Advanced Nurse Practitioners (ANPs) completing the Quality Assurance Schedule have been asked to carry out a deep dive to check documentation around communication with other Trusts/services. As part of this, we now check that it is documented that a verbal handover has been given. If any issues are identified, this is picked up with the team as part of team meetings/supervision to ensure it is addressed as soon as possible.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue team discussions and daily MDT reminders about documenting and verbally handing over homelessness and other risk information.
Verbatim wording from the response “2. Team meeting discussions:
As you are aware, it was not possible to conclude Andrew's inquest in the one day initially allocated on 14 March 2024, and therefore it was adjourned and later concluded on 3 June 2024. Following the first day of Andrew's inquest, the initial learning identified during day one was picked up, and discussions took place within the team meeting, on 15 March 2024. Those discussions have continued within daily MDT meetings, to remind liaison staff of the importance of documenting, and verbally handing over if a patient reports themselves to be homeless. Conversations continue with regard to ensuring the important information relevant to a patient's risk, is handed over.” Source location Response from Tees, Esk and Wear Valleys 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 Discharge need not normally be delayed for homeless patients when capacity, medical and mental-health fitness, signposting, and community support are in place.
Verbatim wording from the response “4. Discharge arrangements.
As we described to HMAC, the experience of the Liaison team working within CDDFT is that discharge would not usually be delayed for a homeless patient, in circumstances where the patient (1) has capacity, (2) is medically optimised and deemed fit for discharge, (3) is considered fit for discharge following review by the mental health liaison team, (4) has been appropriately signposted to the Local Authority regarding homelessness, and (5) has support in place in the community from the Community Mental Health Team as well as Drug and Alcohol services. Clearly, it is imperative that capacious, homeless patients who are fit for discharge, are given the correct advice, signposting and support around homelessness, but in our experience, this does not mean remaining as an inpatient until accommodation arrangements have been secured.” Source location Response from Tees, Esk and Wear Valleys 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 chlordiazepoxide concern is for CDDFT to address, and CDDFT has reportedly responded.
Verbatim wording from the response “I am writing to you in response to the Prevention of Future Death (PFD) Report issued to Tees, Esk and Wear Valleys NHS Foundation Trust ("TEWV", or "the Trust") on 04.06.2024 following the inquest touching the death of Andrew Naylor. I note that the PFD Report issued has been directed to both TEWV and County Durham and Darlington NHS Foundation Trust (CDDFT), on the basis you have concerns in respect of both organisations. I have not responded to point 5(1) as this issue relating to Chlordiazepoxide, appears to be for CDDFT to respond to and I am assured that they have responded.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
Concerns raised 4 Failure to effectively implement actions arising from thematic reviews View source Delays in implementing lessons and patient-safety improvements from serious incident investigations View source Delays in completing serious incident investigations View source Failure to preserve evidence while memories are fresh during serious incident investigations View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Linda Louise Banks · 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
Linda Louise Banks died at the University Hospital of North Durham on 10 April 2022 after taking a paracetamol overdose, against a background of alcohol misuse and deteriorating mental health. The report identified concerns about the quality of mental health assessments, triage, safety planning and record keeping, the underestimation of risk, failure to identify possible learning difficulties and provide reasonable adjustments, and delays in investigating the care provided. It also identified concerns that similar issues found in an earlier thematic review had not been effectively addressed.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively implement actions arising from thematic reviews
Wider context from the report “(1) A thematic review completed in November 2021 had identified a number of significant issues in the functioning of mental health services, and many of the same issues were also identified in the serious incident review into Linda’s care and treatment, from February 2022 until her death. It is apparent that any actions taken as a result of the thematic review were not effective in implementing change and that the action plan was still a “work in progress” at the Pre Hearing Review Hearings which took place in this case in 2023.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing lessons and patient-safety improvements from serious incident investigations
Wider context from the report “(3) As previously reported the concern in relation to the delays in such investigations and any subsequent necessary action required, is twofold. Firstly, the quality of the investigation is severely compromised as the evidence is not captured when memories are fresh. Secondly, because any lessons to be learnt and improvements to be made to improve patient safety cannot be implemented promptly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing serious incident investigations
Wider context from the report “(2) The Serious Incident Investigation into the care received by Linda was not completed until the end of January 2023, some 9 months after the death . This is neither timely nor responsive . Despite reassurances given that the Trust are working to eradicate such delays, in response to a series of previous PFD reports issued by the Coroners of Durham and Darlington, there are still cases coming to the attention of the Coronial service where Serious Incident Investigations are significantly delayed in excess of the 60 day NHS framework .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve evidence while memories are fresh during serious incident investigations
Wider context from the report “(3) As previously reported the concern in relation to the delays in such investigations and any subsequent necessary action required, is twofold. Firstly, the quality of the investigation is severely compromised as the evidence is not captured when memories are fresh . Secondly, because any lessons to be learnt and improvements to be made to improve patient safety cannot be implemented promptly.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the outstanding training required under the Crisis Team improvement plan.
Verbatim wording from the response “As advised at the inquest, the action plan for the thematic review was reviewed and incorporated into a larger overarching improvement plan for the Durham and Darlington Crisis Team following a restructure of its operational management and governance processes and arrangements in April 2022. This meant that whilst all the points had been actioned, some work was still being carried out at the time of the Pre-Inquest Review Hearings to continue to refine and improve the Crisis Team and ensure any changes were fully embedded. As heard at the inquest and set out in the statement of Thomas Hurst, all actions have been addressed, with a plan for outstanding training to be completed, however if you wish for further clarity on any particular action please let me know.” Source location Response from Tees, Esk and Wear Valleys 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 Operate the fully transitioned PSIRF arrangements, including the implemented InPhase incident-reporting system and associated processes.
Verbatim wording from the response “The Patient Safety Incident Response Framework (PSIRF) will replace the current Serious Incident Framework 2015. This represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. This is a key part of the national NHS Patient Safety Strategy, which recognises that new ways of learning are required to drive change and improve standards.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue refining and embedding Durham and Darlington Crisis Team improvements through the overarching improvement plan.
Verbatim wording from the response “As advised at the inquest, the action plan for the thematic review was reviewed and incorporated into a larger overarching improvement plan for the Durham and Darlington Crisis Team following a restructure of its operational management and governance processes and arrangements in April 2022. This meant that whilst all the points had been actioned, some work was still being carried out at the time of the Pre-Inquest Review Hearings to continue to refine and improve the Crisis Team and ensure any changes were fully embedded. As heard at the inquest and set out in the statement of Thomas Hurst, all actions have been addressed, with a plan for outstanding training to be completed, however if you wish for further clarity on any particular action please let me know.” Source location Response from Tees, Esk and Wear Valleys 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 PFD appears to arise from unrelated advice about a future investigation, not outstanding concerns from evidence heard at this inquest.
Verbatim wording from the response “It was therefore disappointing to receive a further PFD on this matter. I was further confused that the PFD in this case appears to have been issued in relation to you being advised on another unrelated matter that an SII would not be completed until January 2024, when the death occurred in October, and not due to any outstanding concerns in relation to the evidence heard at this inquest.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
Concerns raised 1 Failure to complete serious incident investigations in a timely and responsive way 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
Sarah Elizabeth Holmes · 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
Sarah Elizabeth Holmes, who had a history of mental health difficulties and self-harm, was found dead after discharge home following a mental health assessment; the medical cause of death was recorded as asphyxia. The principal concern was the substantial delay in the Trust’s serious incident investigation, which remained incomplete more than a year after her death and was described as neither timely nor responsive. The report also raised concern that such delays could allow lethal hazards to persist and compromise investigations intended to prevent similar deaths.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete serious incident investigations in a timely and responsive way
Wider context from the report “(1) The serious incident investigation by the Trust has been substantially delayed. Sarah died on the 10th of July 2022 and the Trust confirmed to the Coroner’s service that there was to be a serious incident investigation on the 26th July 2022. The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months and on the 13th of March 2023 as this remained the position I listed this case for inquest on the 24th April 2023. On the 17th April 2023 I was alerted by deceased’s family to possible progress in respect of the serious incident investigation in this case, subsequent to their formal complaint to the Trust. After making enquiries of the Trust I was informed that the report would be available at the end of May 2023 and I therefore acceded to a family request to adjourn the final hearing given the short delay this would cause. On the 25th of April 2023 the Coronial service was informed that in fact that it was unlikely that the report would be finalised by May and would be ‘likely end of July/August time’. On the 26th of June I was informed that the report would now not be available until the ‘end of September/beginning of October’ and that the initial dates given were “too ambitious”. The case was listed to commence on the 16th of November 2023 on that basis. On the 28th of July the deceased’s family notified me of a likely further delay in the report being available due to the author’s sick leave from work. The Trust offered reassurance that the report remained due ‘end of September/beginning of October’. On the 28th of September a Pre Inquest Review Hearing was held in relation to a separate discrete issue and I was informed that the report was to be further delayed and would not be available until the end of October.
(2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again.
(3) If the final version report is received by the end of October it will be some 15 months since Sarah’s death and some 13 months outside the NHS framework. This is neither timely nor responsive.
(4) I have previously issued a PFD report in relation to this issue as has the Senior Coroner for Durham and Darlington, Mr Chipperfield, who stated that Tees Esk and Wear Valleys NHS Foundation Trust routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths.
(5) I am concerned that these dangers persist, despite the Trust’s response to previous PFD reports and their assurances that remedial action was being taken to eradicate the delays , and as a result it is my statutory duty to make this further report.
” Open source report
Concerns raised 1 Failure to complete serious incident investigations within required timescales View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian Darwin · 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
Ian Darwin died from multiple injuries after being found below ████████, Durham, on 6 March 2023. The report raises concern that Tees Esk and Wear Valleys NHS Foundation Trust routinely delays serious incident investigations, potentially allowing lethal hazards to persist and compromising investigations intended to prevent avoidable deaths. The inquest had not been heard and the investigation had not concluded at the time of the report.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete serious incident investigations within required timescales
Wider context from the report “Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”) routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations , TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths.
The above-mentioned inquest has not been heard; there has been no finding that the present death was attributable to acts or omissions in care.
Although arising in the present investigation, the matter of concern is general and has arisen in the context of other investigations. Despite past assurances that the material circumstances have been addressed, the facts of the present case demonstrate that they continue to exist. I am aware that on 19th July 2023, Assistant Coroner Janine Richards notified you of the same concern arising from matters revealed by another investigation.
TEWV identified Ian Darwin’s death as a “serious incident” (“SI”) for the purposes of The Serious Incident Framework¹ (the Framework”). The SI investigation (“SI”) process-defined in the Framework- was the means employed by TEWV to investigate this SI.
The Framework defines SIs as “events where the potential for learning is so great, or the consequences to patients… so significant that they warrant particular attention to ensure these incidents… are investigated thoroughly… and trigger actions that will prevent them from happening again”. SIs “include acts or omissions in care that result in… avoidable death…”. Further, the “occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm”. SI investigations are the means “to ensure that weaknesses in a system are identified, to understand what went wrong … and what can be done to prevent similar incidents happening again”.
Discussing one of the seven key principles of the SI investigation- that they be Timely and Responsive- the Framework requires that SIs “must be reported without delay and no longer than 2 working days after the incident is identified”. One of “two key operational changes” introduced in the 2015 update was a single timeframe of 60 working days (from date of initial report) for completion of investigation reports. At an “early meeting” the investigator must “set out a realistic and achievable timescales and outcomes”.
The present case:
• Death occurred on 06.03.23;
• I am informed that an investigator was initially appointed in around mid-June 2023;
• By late June, TEWV were “unable to say” when the investigation would be complete ;
• The investigation is now expected to be complete in the week commencing 21.08.23 and its report to be finalised 18.09.23
The general situation:
• TEWV SI death investigations, at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification;
• In some other cases delay is significantly longer than in the present ;
• Such delays affect cases of all levels of seriousness.
” 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 Contract an external professional incident-review provider.
Verbatim wording from the response “11) We will continue to expand our range of subject matter expert categories to lead specific types of reviews and we are currently contracting with an external provider who are a professional incident review company. Again, this is an opportunity to avoid delays in the future.” Source location Response from Tees,Esk and Wear Valleys 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 Modify documentation, review report templates and use standard operating procedures to support efficient review workflows.
Verbatim wording from the response “9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow.” Source location Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt daily patient-safety-huddle processes to identify the required type of incident review earlier.
Verbatim wording from the response “5) We have adopted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be PSIRF, guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance.” Source location Response from Tees,Esk and Wear Valleys 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 Maintain direct oversight of serious incident review performance and brief the Quality Assurance Committee and Board.
Verbatim wording from the response “I am responding in the same format and with similar information to that in the response letter sent last month, I hope this consistency will be helpful in enabling you and your team to see the clear evidence of the progress we are making towards providing timely serious incident reviews. I have continued to have direct oversight of how we are performing as I am concerned that we improve our position as soon as possible. Our CEO and our Board share this concern and therefore I am keeping our Quality Assurance Committee and our Board fully briefed.” Source location Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase internal capacity by engaging leaders to complete incident reviews and prevent further delays.
Verbatim wording from the response “2) We have increased our internal capacity to review incidents by engaging our leaders in completing incident reviews in order that we can review incoming incidents and avoid further delays developing. We intend to continue to use some of this capacity and expertise in the future which is part of our plan to avoid delays in the future.” Source location Response from Tees,Esk and Wear Valleys 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 Contract additional expert capacity to address delayed serious incident reviews.
Verbatim wording from the response “1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed, this is a group of incidents that happened before February 2023. Some of these reviews are now being concluded and are going through the internal quality assurance checks before we share them with the families, submit to the ICS and to your office. The attached document gives the detail of this.” Source location Response from Tees,Esk and Wear Valleys 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 Operate weekly review-progress meetings and monitor performance against the improvement trajectory.
Verbatim wording from the response “7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis.” Source location Response from Tees,Esk and Wear Valleys 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 Expand subject-matter-expert categories to lead specific review types.
Verbatim wording from the response “11) We will continue to expand our range of subject matter expert categories to lead specific types of reviews and we are currently contracting with an external provider who are a professional incident review company. Again, this is an opportunity to avoid delays in the future.” Source location Response from Tees,Esk and Wear Valleys 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 Exact completion dates for some serious incident reports cannot be predicted because final reports may not be available for review on time.
Verbatim wording from the response “I have taken the opportunity to share a list of the serious incident reviews that we believe will be required by you and I have indicated the dates that we expect the internal quality assurance process to be taking place. You can reasonably expect to receive most finalised serious incident reports within 2 weeks of the internal review however some will take longer than two weeks depending on, and this is difficult to predict, when the final report is available for review.” Source location Response from Tees,Esk and Wear Valleys NHS Foundation Trust
Open published response
Concerns raised 2 Failure to promptly obtain, secure and preserve relevant serious-incident evidence View source Extensive and continuing delays in investigating serious incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kenneth Rippon · 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
Kenneth Rippon had deteriorating mental health, including self-harm, suicidal ideation and command auditory hallucinations, and died on 5 May 2022 after jumping or falling from a viaduct at Durham Train Station. The report identified concerns about inadequate mental health assessments and risk information, insufficient family involvement in safety and discharge planning, and delays and weaknesses in the investigation of the serious incident.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly obtain, secure and preserve relevant serious-incident evidence
Wider context from the report “(1) The serious objective investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with.
(2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again.
(3) The delay in the investigation in this case is particularly concerning in a number of respects, not least in that it revealed problems in clinical record keeping, risk assessments and the consideration of hospital admission, lack of family/carer involvement, lack of comprehensive mental state examination/assessment including capacity, safeguarding and social needs and medication review and access to services.
(4) As a result of the delay in the serious incident Investigation and formulation of an action plan, many of the identified actions required to remedy these difficulties were still being actioned /completed relatively recently.
(5) Further one of the actions upon identification of a serious incident is to obtain, secure and preserve all relevant evidence. In this case the memory capture forms identified as being required in the immediate aftermath of the incident were not taken promptly and were seemingly only taken after I requested sight of them, several months after the incident and therefore when memories had already begun to fade. This was concerning given the identified problem of clinical record keeping at the time of these events.
(6) I am concerned that the extensive and continuing delays in investigating serious incidents may lead to further deaths, as lessons cannot be learnt and improvements made in a timely manner. I am also concerned that the quality of such investigations is compromised by the failure to complete memory capture forms and the passage of time before important evidence is secured .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Extensive and continuing delays in investigating serious incidents
Wider context from the report “(1) The serious objective investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with.
(2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again.
(3) The delay in the investigation in this case is particularly concerning in a number of respects, not least in that it revealed problems in clinical record keeping, risk assessments and the consideration of hospital admission, lack of family/carer involvement, lack of comprehensive mental state examination/assessment including capacity, safeguarding and social needs and medication review and access to services.
(4) As a result of the delay in the serious incident Investigation and formulation of an action plan, many of the identified actions required to remedy these difficulties were still being actioned /completed relatively recently.
(5) Further one of the actions upon identification of a serious incident is to obtain, secure and preserve all relevant evidence. In this case the memory capture forms identified as being required in the immediate aftermath of the incident were not taken promptly and were seemingly only taken after I requested sight of them, several months after the incident and therefore when memories had already begun to fade. This was concerning given the identified problem of clinical record keeping at the time of these events.
(6) I am concerned that the extensive and continuing delays in investigating serious incidents may lead to further deaths, as lessons cannot be learnt and improvements made in a timely manner. I am also concerned that the quality of such investigations is compromised by the failure to complete memory capture forms and the passage of time before important evidence is secured.
” 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 Modify documentation, review report templates and use standard operating procedures to improve efficient review workflow.
Verbatim wording from the response “9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an external specialist company to review historical incident data and identify risks from delayed reviews.
Verbatim wording from the response “4) An external company specialising in incident management has reviewed our historical incident data so that we can address the potential risks of missing issues and learning due to a delay with some reviews.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Serious Incident Review Panel capacity to prevent internal quality assurance delaying review release.
Verbatim wording from the response “10) We have increased our internal Serious Incident Review Panel capacity to ensure we can be efficient in our internal quality assurance in order that this does not delay the release of reviews to families once completed.” Source location Response from Tees, Esk and Wear Valleys 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 Hold weekly review-progress meetings, provide reviewer support and monitor performance against the review trajectory.
Verbatim wording from the response “7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue expanding subject matter expert categories to lead specific types of incident reviews.
Verbatim wording from the response “12) We will continue to expand our range of subject matter expert categories to lead specific types of reviews.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.
Verbatim wording from the response “2) We have continued to increase our internal capacity to review incidents, our clinical and leaders are engaged across services in completing incident reviews in order that we can review incoming incidents and avoid further delays developing.” Source location Response from Tees, Esk and Wear Valleys 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 Establish Associate Director of Patient Safety and Deputy Chief Nurse roles to oversee review quality and support reviewer supervision.
Verbatim wording from the response “13) The Associate Director of Patient Safety commenced in post as planned from 19 July 23 and is being supported by the Deputy Chief Nurse who commenced at TEWV 3 July 2023. Together they are ensuring that reviews are of the right standard and that reviewers have the right support and supervision to complete high quality reviews.” Source location Response from Tees, Esk and Wear Valleys 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 Contract and allocate additional expert reviewers to address delayed incident reviews.
Verbatim wording from the response “1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed. Since, my previous update we have contracted / employed further reviewers and to date we have allocated 41 of these reviews which is an increase of 16 since my previous letter to you.” Source location Response from Tees, Esk and Wear Valleys 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 Adapt processes to identify the required incident review type earlier through daily patient safety huddles.
Verbatim wording from the response “5) We have adapted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be Patient Safety Incident Response Framework (PSIRF), guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue expanding subject-matter-expert categories to lead specific types of incident reviews.
Verbatim wording from the response “12) We will continue to expand our range of subject matter expert categories to lead specific types of reviews.” Source location Response from Tees, Esk and Wear Valleys 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 Modify documentation, review report templates and use standard operating procedures to improve review efficiency and workflow.
Verbatim wording from the response “9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow.” Source location Response from Tees, Esk and Wear Valleys 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 Establish senior patient-safety leadership roles to oversee review standards and provide reviewers with support and supervision.
Verbatim wording from the response “13) The Associate Director of Patient Safety commenced in post as planned from 19 July 23 and is being supported by the Deputy Chief Nurse who commenced at TEWV 3 July 2023. Together they are ensuring that reviews are of the right standard and that reviewers have the right support and supervision to complete high quality reviews.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an external incident-management specialist to review historical incident data and identify risks from delayed reviews.
Verbatim wording from the response “4) An external company specialising in incident management has reviewed our historical incident data so that we can address the potential risks of missing issues and learning due to a delay with some reviews.” Source location Response from Tees, Esk and Wear Valleys 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 Hold weekly review-progress meetings and monitor performance against the established trajectory with executive reporting.
Verbatim wording from the response “7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.
Verbatim wording from the response “2) We have continued to increase our internal capacity to review incidents, our clinical and leaders are engaged across services in completing incident reviews in order that we can review incoming incidents and avoid further delays developing.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Serious Incident Review Panel capacity to support quality assurance without delaying release of completed reviews.
Verbatim wording from the response “10) We have increased our internal Serious Incident Review Panel capacity to ensure we can be efficient in our internal quality assurance in order that this does not delay the release of reviews to families once completed.” Source location Response from Tees, Esk and Wear Valleys 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 Contract and deploy additional expert capacity to address delayed incident reviews.
Verbatim wording from the response “1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed. Since, my previous update we have contracted / employed further reviewers and to date we have allocated 41 of these reviews which is an increase of 16 since my previous letter to you.” Source location Response from Tees, Esk and Wear Valleys 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 Identify required review types earlier through daily patient-safety huddles using national PSIRF guidance.
Verbatim wording from the response “5) We have adapted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be Patient Safety Incident Response Framework (PSIRF), guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance.” Source location Response from Tees, Esk and Wear Valleys 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 Report weekly to Executive Directors on Duty of Candour compliance and review-related delays.
Verbatim wording from the response “have a clear term of reference for each review. We report weekly to the Executive Directors on our compliance with Duty of Candour to ensure there are no delays.” Source location Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Open published response
Concerns raised 4 Failure to make safeguarding referrals for children in all warranted situations View source Failure to complete Safety Plans in all cases View source Failure to complete the Triage Tool at every Crisis Team contact View source Failure to complete timely mental health crisis assessment within the set time period 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
Nicholas James STOUT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nicholas “Nicky” Stout died at Darlington Memorial Hospital on 26 July 2021 after consuming a large quantity of cocaine, with acute cocaine toxicity and coronary artery atheroma recorded as factors. The report raised concerns about delays in mental health crisis assessment, incomplete crisis-team triage tools, safeguarding referrals for children, and the absence or incomplete use of safety plans.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals for children in all warranted situations
Wider context from the report “3. In relation to making safeguarding referrals for children, the evidence I heard was in this particular case a referral should have been made and was not . I was told training had been undertaken to make all staff aware of what action to take. However, I was told in the majority of occasions it was believed a referral would be made. It is of concern in terms of protecting children that I was not satisfied that a referral was made in all situations that warranted such a referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Safety Plans in all cases
Wider context from the report “4. I was told in evidence that a Safety Plan which is complied with input from the patient, their families and practitioners did not exist in Mr STOUT's case. I was told it is crucial document for identifying risks and ways to mitigate them. I was also told work was commenced by your organisation in December 2020 to ensure full and complete compliance with this requirement, but I was not reassured there was such compliance with the completion of Safety Plans in all cases at this time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the Triage Tool at every Crisis Team contact
Wider context from the report “2. The Triage Tool was explained in evidence to be essential in ensuring the patient received the correct treatment/service and is to be undertaken every time a patient contacts the Crisis Team. I was informed there was an aspiration to achieve a completion of the Triage Tool every time, but it is not being completed on every occasion . It is of concern that such a key document which identifies risk, care and other matters is not completed on every occasion as it is mandated to be done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete timely mental health crisis assessment within the set time period
Wider context from the report “1. The nationally set time from initial contact with the Crisis Team to some form of assessment is 4 hours. I heard evidence that achievement of this target in every case is not realised . It is of concern that timely assessment and treatment of person undergoing a mental health crisis should be assessed as speedily as possible and within the set time period .
” Open source report
10 Aug 2022 Allan Michael WADDUP · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 5 Failure to triage mental health self-referrals within 24 hours View source Failure to make in-person contact before discharging mental health patients who do not attend appointments View source Lack of weekend triage for mental health referrals View source Failure to provide inmates with appointment letters notifying them of planned mental health appointments View source Failure to display kiosk warnings directing inmates to urgent assistance 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
Allan Michael WADDUP · 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
Allan Michael WADDUP died in prison on 13 December 2019 after seeking mental health support. He had been referred and later self-referred, but was discharged without an assessment, was not assessed before his death, and concerns were raised about appointment notification, the Did Not Attend process, delays in triage, and the absence of weekend triage or urgent-assistance guidance on the prison kiosk.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to triage mental health self-referrals within 24 hours
Wider context from the report “(2) Mr Waddup was referred to mental health on 30 October 2019. Attempts were made to assess him in his cell over the telephone on 14, 19 and 21 November 2019. He was discharged from mental health on 2 December 2019 without an assessment being undertaken. There was no in person contact to explore the reasons he did not attend those appointments prior to discharge. It could not be confirmed he was personally aware of those appointments. He self-referred on 5 December 2019 and was not triaged within 24 hours or assessed prior to his death. An immediate review of the Did Not Attend (DNA) policy for the mental health services to include an in person contact is being undertaken prior to discharge but has not been completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make in-person contact before discharging mental health patients who do not attend appointments
Wider context from the report “(2) Mr Waddup was referred to mental health on 30 October 2019. Attempts were made to assess him in his cell over the telephone on 14, 19 and 21 November 2019. He was discharged from mental health on 2 December 2019 without an assessment being undertaken. There was no in person contact to explore the reasons he did not attend those appointments prior to discharge. It could not be confirmed he was personally aware of those appointments. He self-referred on 5 December 2019 and was not triaged within 24 hours or assessed prior to his death. An immediate review of the Did Not Attend (DNA) policy for the mental health services to include an in person contact is being undertaken prior to discharge but has not been completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of weekend triage for mental health referrals
Wider context from the report “(3) Mr Waddup self-referred via the kiosk system. There is no triaging of referrals on a weekend. A disclaimer or warning directing inmates to how to seek urgent assistance is not currently displayed on the kiosk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide inmates with appointment letters notifying them of planned mental health appointments
Wider context from the report “(1) Mr Waddup was referred to mental health on 29th October 2019 on triaged within 24 hours on 30th October 2019. Attempts were made to assess him by telephone on 14, 19 and 21 November 2019. It is not clear if Mr Waddup personally knew of the appointments. Appointment letters are currently not sent to inmates at HMP Northumberland to notify them of planned appointments. Prisoners could be notified on the day via the appointment scheduling process within the prison whereby the wing is notified of who has appointments with various departments. I heard that TEWV provide mental health services across the North East cluster of prisons including four prisons in the North West. In some custodial facilities an appointment letter is sent. This system is not replicated in HMP Northumberland
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to display kiosk warnings directing inmates to urgent assistance
Wider context from the report “(3) Mr Waddup self-referred via the kiosk system. There is no triaging of referrals on a weekend. A disclaimer or warning directing inmates to how to seek urgent assistance is not currently displayed on the kiosk.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request that the revised discharge process be incorporated into the Trust-wide discharge policy.
Verbatim wording from the response “Following the inquest, an immediate lessons learned bulletin was shared with all staff working across the service within the Trust, advising at the point of discharge, appointments must take place face to face. A service level meeting was also convened to share the information and requirements with Team Managers, so ensure information was filtered down to all staff. The Operational Policy for the service has been updated to reflect the updated discharge process and a request has been made to ensure upon review (in January 2023) this is also reflected in the trust wide discharge policy.” Source location Response from NHS Tees, Esk and Wear Valleys
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the service Operational Policy to reflect the revised face-to-face discharge process.
Verbatim wording from the response “Following the inquest, an immediate lessons learned bulletin was shared with all staff working across the service within the Trust, advising at the point of discharge, appointments must take place face to face. A service level meeting was also convened to share the information and requirements with Team Managers, so ensure information was filtered down to all staff. The Operational Policy for the service has been updated to reflect the updated discharge process and a request has been made to ensure upon review (in January 2023) this is also reflected in the trust wide discharge policy.” Source location Response from NHS Tees, Esk and Wear Valleys
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 Request electronic kiosk referrals with referral-processing timeframes and urgent-contact information from the prison provider.
Verbatim wording from the response “The prison service provider at HMP Northumberland has granted the request to remove the ability to refer to mental health services via kiosk. Due to the restrictions on the prison kiosk system, men are unable to give any detailed rationale for the appointment request making triage processes difficult for the team upon receipt of the request. A request has been made to the prison provider at HMP Northumberland as to whether an electronic referral can be uploaded to the kiosk system, as well as a notification advising patients of timeframes for referrals to be processed and who to contact, and how, in an urgent situation.” Source location Response from NHS Tees, Esk and Wear Valleys
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 reviewed and updated appointment letter templates across prison establishments, including HMP Northumberland.
Verbatim wording from the response “Appointment letter templates have been reviewed and updated and have now been introduced across all prison establishments, including HMP Northumberland where TEWV provide Mental Health care delivery. As part of this process of review, the letter content has been reviewed to ensure its content is succinct and clear, dated and provides the relevant information.” Source location Response from NHS Tees, Esk and Wear Valleys
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Did Not Attend policy to require in-person contact before mental-health discharge.
Verbatim wording from the response “(2) Mr Waddup was referred to mental health on 30 October 2019. Attempts were made to assess him in his cell over the telephone on 14, 19 and 21 November 2019. He was discharged from mental health on 2 December without an assessment being undertaken. There was no in person contact to explore the reasons he did not attend those appointments prior to discharge. It could not be confirmed he was personally aware of those appointments. He self-referred on 5 December 2019 and was not triaged within 24 hours or assessed prior to his death. An immediate review of the Did Not Attend (DNA) policy for the mental health services to include an in person contact is being undertaken prior to discharge but has not been completed.” Source location Response from NHS Tees, Esk and Wear Valleys
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 self-referral forms, including easy-read versions, with questions enabling triage by service need and urgency.
Verbatim wording from the response “Self-referrals, including easy read versions, are available to all men on wing locations. The referral asks specific questions which allow the team to triage the referral appropriately in relation to service required, as well as urgency.” Source location Response from NHS Tees, Esk and Wear Valleys
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 Share discharge lessons and face-to-face appointment requirements with service staff and Team Managers.
Verbatim wording from the response “Following the inquest, an immediate lessons learned bulletin was shared with all staff working across the service within the Trust, advising at the point of discharge, appointments must take place face to face. A service level meeting was also convened to share the information and requirements with Team Managers, so ensure information was filtered down to all staff. The Operational Policy for the service has been updated to reflect the updated discharge process and a request has been made to ensure upon review (in January 2023) this is also reflected in the trust wide discharge policy.” Source location Response from NHS Tees, Esk and Wear Valleys
Open published response
Concerns raised 10 Lack of multidisciplinary clinical assessment and formulation addressing autism View source Gap in acute and crisis mental health support alongside commissioned autism care View source Lack of local specialist autism assessment and adapted psychological therapy View source Failure to understand autism-related trauma in risk assessment View source Failure to respond promptly to distress and remove discounted diagnostic references View source Failure of communication and shared information across autism and mental health teams View source Failure to make timely reasonable sensory and environmental adjustments View source Failure to provide a care coordinator and effective care plan View source Lack of person-centred autism-informed holistic care planning View source Failure to avoid attributing an undiagnosed personality disorder to an autistic patient View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 15
Action
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Communicate learning from Zoe’s death and subsequent inquiries, including the need to validate or review EUPD diagnoses, to relevant clinical and senior medical staff.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Communicate learning from Zoe’s death and inquiries, including the need to validate or review EUPD diagnoses, to clinical and senior medical staff.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Deliver autism-awareness and trauma-informed training addressing reasonable adjustments, autism-related trauma and staff understanding of autistic people’s needs.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Review 134 patients’ autism and EUPD diagnoses, communications, withdrawals, reasonable adjustments and treatment options.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Obtain specialist autism support for community teams to review care quality and reasonable adjustments, while monitoring uptake.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Implement revised risk-assessment and safety-planning tools with associated multidisciplinary training, including autism-specific suicide-risk content.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Adopt nationally recommended collaborative care planning using holistic, individualised recovery plans based on the DIALOG model.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Monitor the action plan requiring flexible, cross-service decisions to meet individual patient needs.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source
Action
Require autism-informed care, treatment, safety summaries and safety plans within multidisciplinary team processes, including patient and advocate involvement where possible.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Provide autism training, supervision and consultation for clinical and non-clinical staff on risk, diagnosis, needs and holistic care planning.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2022. View source
Action
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2022. View source
Action
Develop and embed an autism-informed care-planning process with evaluation and sustainability work for person-centred holistic plans.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022. View source See 12 more actions
×
AI-generated summary
Zoe Emma ZAREMBA · 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
Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary clinical assessment and formulation addressing autism
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism ;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Gap in acute and crisis mental health support alongside commissioned autism care
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local specialist autism assessment and adapted psychological therapy
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy . Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand autism-related trauma in risk assessment
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe .
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond promptly to distress and remove discounted diagnostic references
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution . There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and shared information across autism and mental health teams
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working , that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely reasonable sensory and environmental adjustments
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all ;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care coordinator and effective care plan
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of person-centred autism-informed holistic care planning
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender . As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid attributing an undiagnosed personality disorder to an autistic patient
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”) .
3 That attribution was not formally diagnosed , and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” 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 Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Verbatim wording from the response “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Response from TEWV
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 Communicate learning from Zoe’s death and subsequent inquiries, including the need to validate or review EUPD diagnoses, to relevant clinical and senior medical staff.
Verbatim wording from the response “5) Learning from Zoe’s death and the subsequent inquiries has already been communicated by the patient safety team, and most recently the need to be validating or reviewing any diagnosis of EUPD has been highlighted by the medical director to a meeting of all senior medical staff (1st June 2022).” Source location Response from TEWV
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 Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Verbatim wording from the response “Within the Trust we have identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
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 Communicate learning from Zoe’s death and inquiries, including the need to validate or review EUPD diagnoses, to clinical and senior medical staff.
Verbatim wording from the response “5) Learning from Zoe’s death and the subsequent inquiries has already been communicated by the patient safety team, and most recently the need to be validating or reviewing any diagnosis of EUPD has been highlighted by the medical director to a meeting of all senior medical staff (1st June 2022).” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver autism-awareness and trauma-informed training addressing reasonable adjustments, autism-related trauma and staff understanding of autistic people’s needs.
Verbatim wording from the response “The Trust Board have received training in this essential work so that they are better informed, they remain committed to ensuring that it is embedded into clinical journey and subsequent underpinning practice to seek to understand patient needs. Across the Trust we are delivering autism awareness training to our clinical staff with a focus on how to make reasonable adjustments for autistic people so that they can access and benefit from services. Additionally, we are focussing on avoidance of trauma in this training so the potential to traumatise autistic people is reduced. We humbly accept that if everybody (including staff) understood autism better, then trauma such as Zoe experienced would be reduced.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 134 patients’ autism and EUPD diagnoses, communications, withdrawals, reasonable adjustments and treatment options.
Verbatim wording from the response “Within the Trust we have now identified 134 patients that have both an Autism marker and a documented diagnosis of Emotionally Unstable Personality disorder (EUPD) which includes Borderline Personality Disorder (BPD).” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 Obtain specialist autism support for community teams to review care quality and reasonable adjustments, while monitoring uptake.
Verbatim wording from the response “Within the North Yorkshire teams, and across the trust supervision and support is being sought by the generic community teams on a case-by-case basis from clinical experts, who have an appropriate level of expertise to check and challenge the quality of care being provided. This is not only in relation to the specific care and treatment pathway for the individuals concerned, but also looks at the ability and understanding of the team to provide reasonable adjustments when working with patients who have an autism diagnosis or who present with such traits. This sits alongside the training that is being delivered to local teams to increase knowledge and understanding of these issues.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
Verbatim wording from the response “We have learned from Zoe’s sad death and shared with our clinical teams the importance of communication with our partners, to ensure that patients’ needs are addressed in a more cohesive and person-centred manner.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 revised risk-assessment and safety-planning tools with associated multidisciplinary training, including autism-specific suicide-risk content.
Verbatim wording from the response “As a Trust we do take very seriously our responsibility to ensure that our patients have the most robust multidisciplinary risk assessment facilitated by trained and competent staff. The safety summary is the Trust’s risk assessment tool, and a significant amount of work has been undertaken by the Trust in respect of improving the quality of risk assessments, across both inpatient and community settings to ensure that full and up to date information is included as part of the risk assessment. The harm minimisation training supports an individualised and needs-led approach to risk assessment, and this includes people with Autism and their specific needs. In order to drive this work forward, a Trust-wide quality improvement event was held in August 2021 the Trust Clinical Advisory Group commenced work in reviewing harm minimisation training.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt nationally recommended collaborative care planning using holistic, individualised recovery plans based on the DIALOG model.
Verbatim wording from the response “We are adopting the nationally recommended changes to care planning to ensure that this is more collaborative and focussed on holistic needs with individualised recovery plans based on the DIALOG model. Increasingly, across the system, we
████████
████████” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the action plan requiring flexible, cross-service decisions to meet individual patient needs.
Verbatim wording from the response “There has been a previous external review of Zoe’s care that considers this point and a subsequent action plan which was developed with Mrs Zaremba. These identified as an action that community mental health team leaders need to make flexible decisions based on an individual needs which may need to cross services and traditional ways of working. This may mean that it’s necessary to move away from usual ways of working in relation to allocation of a care coordinator or where care is delivered to ensure that all efforts are made to collaboratively meet patient needs.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 autism-informed care, treatment, safety summaries and safety plans within multidisciplinary team processes, including patient and advocate involvement where possible.
Verbatim wording from the response “To assist staff in practically achieving this goal, additional measures have been introduced into the MDT process to ensure that, where a patient has a diagnosis of autism, their care, treatment, safety summary and safety plan take that diagnosis into account and provide a comprehensive assessment of need. MDT formulation now includes patients and their advocates, wherever possible, in order to ensure honest and transparent communication when reaching a diagnosis.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 autism training, supervision and consultation for clinical and non-clinical staff on risk, diagnosis, needs and holistic care planning.
Verbatim wording from the response “Additionally, we offer as a trust a full day Understanding Autism Training which has a focus on risk assessment for autistic people, diagnosis and associated risks and needs. This training is further consolidated through the offering of individual Autism supervision and consultation for clinical staff.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Verbatim wording from the response “Our new patient recording information system (CITO) will not only allow a greater clarity around active and discounted diagnoses but will importantly also support patient access to their own records improving mutual understanding and effective” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and embed an autism-informed care-planning process with evaluation and sustainability work for person-centred holistic plans.
Verbatim wording from the response “As a trust we offer a full day Understanding Autism training for both clinical and non-clinical staff, which has a focus on developing holistic plans of care for autistic people and reflects diagnosis and associated risks and needs. This is consolidated through the offering of individual autism supervision and consultation for clinical staff. The utilisation of supervision and consultation has increased over the last twelve months ensuring that care plans consider the needs of the autistic patient. Work is actively taking place to ensure that Autistic people’s needs can be reflected within the new care planning process.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
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 In North Yorkshire, autism assessment and support are commissioned from services outside the Trust.
Verbatim wording from the response “• In North Yorkshire the commissioned service for assessment and support is external to the Trust and so the numbers are correspondingly less in terms of those waiting for an assessment.” Source location Response from TEWV
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 Autism assessment and support in North Yorkshire are commissioned from services external to the Trust.
Verbatim wording from the response “• In North Yorkshire the commissioned service for assessment and support is external to the Trust and so the numbers are correspondingly less in terms of those waiting for an assessment.” Source location Reponse from Tees Esk and Wear Valleys NHS Foundation Trust (17 June)
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 Specialist autism assessment and adapted psychological interventions require individual funding and are usually delivered by The Retreat.
Verbatim wording from the response “We acknowledge that commissioning arrangements which are currently led by The Clinical Commissioning Group, are complex and provided by multiple organisations. The current position is that Adult Autism diagnostic services are commissioned through The York Retreat for York and North Yorkshire and are commissioned through TEWV for Durham and Tees Valley.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust (21 June)
Open published response
Concerns raised 5 Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points View source Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients View source Failure to print medical notes and other documents from the Trust IT system in shared premises View source Failure to upload PDF medical records and important information promptly in original form to the electronic notes system View source Limited coverage of the Bed Manager function to one Trust region 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
Mina TOPLEY-BIRD · 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
Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
Wider context from the report “3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given . One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients
Wider context from the report “5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still 'a work in progress' and further work was required . It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to print medical notes and other documents from the Trust IT system in shared premises
Wider context from the report “2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT . This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to upload PDF medical records and important information promptly in original form to the electronic notes system
Wider context from the report “1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form . This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited coverage of the Bed Manager function to one Trust region
Wider context from the report “4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust . On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a central bed management hub as the second phase of the bed management team.
Verbatim wording from the response “In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach:” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, clarify and streamline clinical risk assessment and management processes and confirm organisation-wide risk-assessment standards.
Verbatim wording from the response “Following a CQC inspection in January 2021 where concerns were raised regarding risk assessment and management, a Rapid Process Improvement Workshop (RPIW) was held week commencing 1st February 2021. This was to review, clarify and streamline the process for assessing and managing the clinical risk of patients and to confirm the standards for risk assessment across all services of the organisation.” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Liaison Team overnight staffing to two staff members.
Verbatim wording from the response “The Trust has also since taken action and increased the staffing establishment of the Liaison Team, increasing the number of staff on duty overnight night to two. This means that if a document does need to be printed urgently, one member of staff can go to our nearby Trust premises to do this.” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care documentation to assure that patient risks are assessed and safety plans meet the agreed standard.
Verbatim wording from the response “A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes.” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an out-of-area patient checklist covering information gathering, care-team sharing, Safety Summary updates and forwarding information to admitting wards.
Verbatim wording from the response “As described at the inquest hearing, immediate action was taken by the Trust to develop and implement a checklist to support the care and treatment of patients presenting at Accident and Emergency departments, who are from outside the area. (please see documents attached at Concern 2 below). This checklist includes:” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Cito electronic records functionality for scanning, uploading and viewing documents.
Verbatim wording from the response “This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce locality-based bed managers as the first phase of a Trust-wide bed management team.
Verbatim wording from the response “In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach:” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The environmental survey had included the deceased’s bedroom, contrary to the concern that it had not been inspected for ligature risks.
Verbatim wording from the response “For completeness, MTB was in bedroom 4 (identifier 2.04 previously). The Suicide Prevention Environmental Survey and Risk Assessment, attached below, formed part of the documentary evidence made available to the Coroner. This demonstrated that the survey in place at the time of the incident had included bedroom 4 (2.04).” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
Open published response
Concerns raised 2 Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources View source Failure to provide patients with information about Lamotrigine side effects View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Viktor John Anthony Scott-Brown · 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
Viktor John Anthony Scott-Brown, aged 23, was found hanging at his home overnight on 14/15 December 2018 and pronounced dead at the scene; the inquest concluded that his death was suicide. He had been prescribed Lamotrigine without being warned about its potential association with thoughts of self-harm or suicide, and concerns were raised that reputable prescribing resources were inconsistent or silent about this potential side effect.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with information about Lamotrigine side effects
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” 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 Develop and obtain approval for a Medication Safety Series document on prescribing resources and patient information sources.
Verbatim wording from the response “I would like to reassure you that as an organisation we have taken your concerns seriously. As a consequence we have committed to develop a Medication Safety Series document regarding prescribing resources and sources of patient information. This will be made available to all prescribers. We are aiming to have a draft ready for approval at our Drugs and Therapeutics Committee on 24th September 2020. The final document will then be provided to all prescribers and other relevant staff within the Trust. This is expected to be completed by 2nd October 2020. In addition further communication on this will be provided widely through our Trust Ebulletin. It will also be available on the Trust intranet.” Source location 2020-0163-Response-from-Tees-Esk-and-Wear-Valleys-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the approved Medication Safety Series document and related communications to prescribers and relevant staff through Trust communications and the intranet.
Verbatim wording from the response “I would like to reassure you that as an organisation we have taken your concerns seriously. As a consequence we have committed to develop a Medication Safety Series document regarding prescribing resources and sources of patient information. This will be made available to all prescribers. We are aiming to have a draft ready for approval at our Drugs and Therapeutics Committee on 24th September 2020. The final document will then be provided to all prescribers and other relevant staff within the Trust. This is expected to be completed by 2nd October 2020. In addition further communication on this will be provided widely through our Trust Ebulletin. It will also be available on the Trust intranet.” Source location 2020-0163-Response-from-Tees-Esk-and-Wear-Valleys-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
Concerns raised 2 Failure to record family concerns about suicide risk in the Paris notes View source Unavailability of monitoring or recording of telephone calls 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
Thomas Whitfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Whitfield was a voluntary patient at Farnham Ward, Lanchester Road Hospital, and was found hanging in his room on the morning of 28 July 2016, shortly after being re-assessed by his Consultant Psychiatrist. The concerns included whether information from his sister about perceived suicide risk was communicated and recorded, and the absence of monitoring or recording of telephone calls that might have clarified what was said.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record family concerns about suicide risk in the Paris notes
Wider context from the report “The deceased’s sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient. A Consultant Psychiatrist gave evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.
Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time. There is CCTV in the hospital, which can be viewed after an event to clarify what did/not happen.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of monitoring or recording of telephone calls
Wider context from the report “The deceased’s sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient. A Consultant Psychiatrist gave evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.
Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time. There is CCTV in the hospital, which can be viewed after an event to clarify what did/not happen.
” Open source report
Concerns raised 2 Failure to recognise increased risk from persistently unusual behaviour View source Failure to use appropriate language when describing situations for risk assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Atkinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise increased risk from persistently unusual behaviour
Wider context from the report “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate language when describing situations for risk assessment
Wider context from the report “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk . Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare.
” 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 Promote the approved guidance with partners across the North East prison cluster for which the Trust is responsible.
Verbatim wording from the response “document being approved through agreed governance processes we will actively promote this as partners within the NE prison cluster for which we are responsible. The Regulation 28 notice was also served to G4S and HMP nationally who will respond to this accordingly.” Source location 2017-0021-Response-by-Tees-Esk-and-Wear-Valley-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 specific descriptive language for observed behaviours and discuss the requirement with prison mental health staff.
Verbatim wording from the response “Within the prison Mental Health services we have addressed the use of the term ‘ligature’ and staff are now describing what they observe more specifically. The requirement to do this has been discussed with all staff via discussion at team meetings. The Trust will work with partners to agree the guidance document which has been drafted. Following the” Source location 2017-0021-Response-by-Tees-Esk-and-Wear-Valley-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 Work with partners to agree the drafted guidance document through the agreed governance processes.
Verbatim wording from the response “Within the prison Mental Health services we have addressed the use of the term ‘ligature’ and staff are now describing what they observe more specifically. The requirement to do this has been discussed with all staff via discussion at team meetings. The Trust will work with partners to agree the guidance document which has been drafted. Following the” Source location 2017-0021-Response-by-Tees-Esk-and-Wear-Valley-NHS-Trust
Open published response
Concerns raised 7 Delays in escalating contact with relatives, police, hospital staff and medical staff after a patient’s absence View source Delays in responding to a patient’s absence from leave View source Failure to update risk assessments, case notes and intervention plans with self-harm, suicide and escorted-leave information View source Failure to conduct an assessment before handover View source Failure to ensure that leave arrangements are understood by patients and communicated to relatives View source Failure to carry out required internal, grounds, staff and CCTV searches for a missing patient View source Lack of staff knowledge of leave and missing-patient policies 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
Michael Peter McMonigle · 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
Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating contact with relatives, police, hospital staff and medical staff after a patient’s absence
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to a patient’s absence from leave
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments, case notes and intervention plans with self-harm, suicide and escorted-leave information
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an assessment before handover
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that leave arrangements are understood by patients and communicated to relatives
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required internal, grounds, staff and CCTV searches for a missing patient
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of leave and missing-patient policies
Wider context from the report “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular.
(2) The failure to follow the policy in terms of conducting an assessment prior to the handover.
(3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025.
(4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family.
(5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave.
(6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.
(6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate.
” Open source report
Concerns raised 2 Failure to consider physical effects of ingested foreign bodies and their link to abdominal pain View source Absence of a clear treatment and observation plan for ingested foreign bodies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pamela Gressman · 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
Pamela Gressman died following the ingestion of foreign bodies, one or more of which led to a perforation of the colon; the inquest recorded hospital-acquired pneumonia as the medical cause of death. The report raised concern that insufficient consideration was given to the possible physical effects of the ingested objects and that there was no clear treatment and observation plan.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider physical effects of ingested foreign bodies and their link to abdominal pain
Wider context from the report “Whilst it is clear that considerable attention was given to the deceased’s mental health, insufficient consideration or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had and which led to her period of hospitalisation. Thus little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. The absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear treatment and observation plan for ingested foreign bodies
Wider context from the report “Whilst it is clear that considerable attention was given to the deceased’s mental health, insufficient consideration or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had and which led to her period of hospitalisation. Thus little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. The absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the observation and engagement procedure to consider enhanced observations after foreign-object ingestion.
Verbatim wording from the response “• A review of the observation and engagement procedure will include consideration of a period of enhanced observations for a period of time following ingestion of a foreign object to enable close monitoring of any physical side effects but also to monitor if any foreign bodies are passed through stools. Completed” Source location 2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-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 Work with the local Emergency Department to design and share standard work requiring thorax and abdominal X-rays in relevant cases.
Verbatim wording from the response “• Liaison colleagues to work with the local Emergency Department to ensure standard work is designed and shared to ensure X-rays are done of thorax and abdomen in such instances.
To be completed by 31st October 2016.” Source location 2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-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 Deliver formal training on delayed physical effects, stool checks, risk and intervention plans, and recording related observations.
Verbatim wording from the response “• Formal training sessions to be delivered to specifically include:
◦ Consideration of the possibility of physical effects (sometimes delayed for days) following swallowing of foreign objects, in particular for patients with known history of this
◦ Clarification of process to check if foreign bodies have been passed in stools by patient
◦ The requirement to have a risk management plan and intervention plan to monitor and manage physical health care symptoms of concern and the need to record related observations (10 case notes to be audited).
To be completed 31st October 2016 (delayed due to the challenges of delivering training during the holiday period).” Source location 2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
Open published response
Concerns raised 4 Failure to give sufficient weight to mental health staff opinions in ACCT reviews View source Failure of ACCT review members to read the ACCT document before reviews View source Failure to ensure mental health staff attend relevant ACCT reviews View source Failure to share mental health information with other ACCT review members View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Geraldine Liege Kilborn · 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
Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to mental health staff opinions in ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight . It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT review members to read the ACCT document before reviews
Wider context from the report “(2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and opined their face to face assessment of the prisoner at the time. In this case, some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change “like a light switch” and therefore face to face presentation could well be misleading. Thus in cases where the ACCT review was dealing with a particularly complex challenging prisoner and where an enhanced review was called for, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health staff attend relevant ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health information with other ACCT review members
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” 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 Provide weekend Mental Health Team staffing, prioritising ACCT review attendance and support for women in crisis, with access to an on-call Mental Health Manager.
Verbatim wording from the response “Regarding availability of staff, TEWV have already made changes to the availability of the Mental Health Team staff over the weekend. Staff are on duty between 9.30 am – 12.30pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. The ACCT Case Manager would also have access to an on-call Mental Health Manager. This” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-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 Ensure Mental Health Team management attends daily healthcare and Governor’s morning meetings, with deputy cover when the manager is unavailable.
Verbatim wording from the response “We have also completed the following action to ensure proper and timely communication between prison wing staff and Mental Health Team members: the Mental Health Team Manager attends both the daily healthcare and Governor’s morning meeting to ensure pertinent issues are discussed. A deputy will also attend the healthcare meeting if the MHT manager is not available e.g. on leave.” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-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 Increase multidisciplinary meetings for prisoners with complex care and risk needs to support shared understanding, problem-solving and ACCT contributions.
Verbatim wording from the response “Since the death of Ms Kilborn the use of multi-disciplinary meetings has increased for those prisoners with complex care and risk needs. This is a proactive approach as, through the multi-disciplinary discussion, all issues can be addressed and understood, problems can be appropriately addressed and consensus decisions reached. This therefore enables the Mental Health Team to contribute appropriately to the ACCT process.” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-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 Disseminate requirements to review ACCT documents and System One notes through clinical governance, staff meetings and Mental Health Team training.
Verbatim wording from the response “This relevant point was discussed at our clinical governance meeting and staff meetings within the Mental Health Team. It is also part of the ACCT training delivered to all the staff working in the Mental Health Team. Staff were reminded to read all the relevant information in the ACCT document and on System One notes.” Source location 2014-0532-Response-by-Tess-Esk-Wear-Valleys-NHS-Trust
Open published response
Concerns raised 8 Failure to consider reasons and pressures underlying refusal of face-to-face assessment View source Failure of the risk assessment policy to specify requirements for in-person assessment View source Failure to obtain or require face-to-face assessment when clinically indicated View source Failure to record the basis for decisions to decline home visits View source Failure to sufficiently enquire into mental state and risk when hearing voices are reported View source Lack of training and understanding for appropriate telephone assessment View source Absence of a clear policy for declining home visits on personal safety and security grounds View source Unclear recording of self-harm risk assessment and conclusions View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jeffrey Gash · 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
Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider reasons and pressures underlying refusal of face-to-face assessment
Wider context from the report “3. Notwithstanding the fact that the deceased declined to attend the hospital for a face to face interview, insufficient weight was given to the reason therefore and whether domestic and other pressures were militating against him attending were not properly considered, if at all .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the risk assessment policy to specify requirements for in-person assessment
Wider context from the report “5. The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a one in-person face to face is being undertaken . Thus, the notes entered on the PARIS system were unclear as to their author’s view of risk of self harm where it was accepted in evidence that full details of the assessment of risk and its conclusion are central to the Crisis Team process. The Trust has carried out an SUI. Certain recommendations have been made and are being implemented. The inquest however, as evidenced above, revealed other issues not dealt with by the SUI and therefore a complete re-evaluation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a complete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and if agreed, implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain or require face-to-face assessment when clinically indicated
Wider context from the report “4. Given that there was an insufficiency of enquiry into the deceased’s state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had not agreed to it voluntarily, then there ought to have been a compulsory 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the basis for decisions to decline home visits
Wider context from the report “2. No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision . The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently enquire into mental state and risk when hearing voices are reported
Wider context from the report “4. Given that there was an insufficiency of enquiry into the deceased’s state of mind and in particular, a failure to further explore the issue of him claiming to hear voices , on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had not agreed to it voluntarily, then there ought to have been a compulsory 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training and understanding for appropriate telephone assessment
Wider context from the report “1. The Crisis Team nurse accepted in evidence that she had not been as forceful as she could and should have been to explore with the deceased his new symptoms, auditory hallucinations, hearing voices. This evidences a lack of training and understanding of the nature of and importance of an appropriate level of telephone 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear policy for declining home visits on personal safety and security grounds
Wider context from the report “2. No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision. The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear recording of self-harm risk assessment and conclusions
Wider context from the report “5. The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a one in-person face to face is being undertaken. Thus, the notes entered on the PARIS system were unclear as to their author’s view of risk of self harm where it was accepted in evidence that full details of the assessment of risk and its conclusion are central to the Crisis Team process . The Trust has carried out an SUI. Certain recommendations have been made and are being implemented. The inquest however, as evidenced above, revealed other issues not dealt with by the SUI and therefore a complete re-evaluation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a complete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and if agreed, implemented.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.
Verbatim wording from the response “Since Mr Gash's sad death, the individual nurse has critically reflected upon this at length with the team manager during her period of informal capability management described under point 1 above. I agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken. The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-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 relevant policies against the findings and produce an implementation plan.
Verbatim wording from the response “The Trust also has a Lone Working Procedure which should be completed for all staff who may in the course of their duties have periods where they are working alone including in the context of a high risk visit. This is to some extent addressed within the SUI report where it is documented that a more assertive approach may have helped with the engagement findings. The policy for these areas will be asked to review the relevant policy against your findings and ensure that these are fully taken into account and an implementation plan produced accordingly.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-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 Conduct periodic quality checks of crisis-team assessments and provide targeted staff feedback.
Verbatim wording from the response “Since that time, periodic checks of her assessments (and assessments done by the rest of the team) have been undertaken by the Consultant Psychiatrist to provide assurance that they are of appropriate quality. This has also enabled us to provide specific feedback to staff as needed to help them develop and improve. We are now assured that the individual nurse has increased her competence and knowledge in telephone assessment skills together with an overall improvement in team performance.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete supervised observation, evaluation and competency development for telephone assessment practice.
Verbatim wording from the response “As you have described, the individual nurse involved in the care of Mr Gash recognised in the inquest that she should have been more detailed in her questioning of him in relation to specific symptoms. This individual has, since the inquest, spent some time reflecting on this with her clinical supervisor. In addition, from September 2013 to January 2014 the individual nurse went through a period of informal capability management. During this time she did not undertake the shift co-ordinator role responsibilities and worked all shifts alongside a more senior and experienced member of the team. She observed best practice assessments and her assessment practice was observed and” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the Trustwide review of clinical risk assessment and management policy and practice, incorporating investigation and inquest information.
Verbatim wording from the response “A Trustwide review of the clinical risk (CRAM) policy and practice is currently underway, with initial reports due in the spring; the information from this Serious Untoward Incident investigation and the inquest will be fed into that review.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-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 Reinforce recording of colleague-reported risks and home-visit decisions in electronic care-record alerts.
Verbatim wording from the response “In relation to recording the information from colleagues, and the individual nurse’s decision making on the shift in question, there is already an ‘alerts’ section in our electronic care record which staff are asked to use to document risks in a way that this information is available to all staff working with a specific patient. The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash’s inquest has further reinforced this via team meetings. In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recommendations with the Specialty's Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-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 Remind staff to explore and use alternative venues for appointments.
Verbatim wording from the response “I also acknowledge the conclusions from the inquest that further options may have been available in the absence of Mr Gash agreeing to see the crisis team at the hospital base, and indeed am aware of instances where staff have used alternative venues for appointments. Staff have been reminded of the need to explore and utilise alternative appointment venues.” Source location 2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
Open published response
Concerns raised 3 Failure to ensure accurate nurse and patient signatures for recorded medication dispensing View source Unauthorised appropriation, trading and stockpiling of patient medication View source Failure to ensure medication is handed directly to the intended patient 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
Edward John Devlin · 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
Edward John Devlin was found dead in his cell at HMP Durham on 17 July 2011, having died from the effects of dihydrocodeine. The report raised concerns that medication, including potentially dangerous drugs, may have been slid under locked cell doors without confirming receipt or administration, creating risks of diversion, inaccurate medication records, stockpiling and potentially lethal overdose. It also found that his physical condition on the night before his death warranted medical assessment, but no such assessment was carried out.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate nurse and patient signatures for recorded medication dispensing
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient.
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him.
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery .
(7) Further, no one would know whether somebody else was appropriating that patient’s medication.
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns.
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unauthorised appropriation, trading and stockpiling of patient medication
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient.
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him.
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery.
(7) Further, no one would know whether somebody else was appropriating that patient’s medication .
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns .
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medication is handed directly to the intended patient
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient .
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him .
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery.
(7) Further, no one would know whether somebody else was appropriating that patient’s medication.
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns.
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.
” Open source report
12 Mar 2014 Andrew Ronald Hall · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 12 Absence of arrangements for staff use of CCTV screens View source Failure to administer prescribed medication View source Failure by healthcare professionals to attend to system 1 entries View source Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk View source Inadequate observation of patients in the healthcare unit View source Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff View source Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers View source Inadequate communication within the Mental Health team about condition and self-harm risk View source Infrequent observation of CCTV screens View source Failure by mental health and general nursing staff to take account of system 1 entries View source Failure to conduct post-closure interviews in accordance with ACCT policy View source Inadequate quality of CCTV images within the healthcare unit View source See 9 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
Andrew Ronald Hall · 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
Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of arrangements for staff use of CCTV screens
Wider context from the report “11. Arrangements for staff members to use the CCTV screens were absent . (Prison service & Healthcare staff)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed . (Medical healthcare staff)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare professionals to attend to system 1 entries
Wider context from the report “5. Insufficient attention was paid by healthcare professionals to the system 1 entries .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk
Wider context from the report “3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of risk of self-harm .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate observation of patients in the healthcare unit
Wider context from the report “9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline officers)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff
Wider context from the report “4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers
Wider context from the report “1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication within the Mental Health team about condition and self-harm risk
Wider context from the report “2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of risk of self-harm .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Infrequent observation of CCTV screens
Wider context from the report “12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by mental health and general nursing staff to take account of system 1 entries
Wider context from the report “6. That both mental health staff and general nursing staff inadequately took into account the entry made by ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct post-closure interviews in accordance with ACCT policy
Wider context from the report “7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted . (Prison staff, healthcare staff and Mental Health team)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of CCTV images within the healthcare unit
Wider context from the report “10. The quality of CCTV images within the healthcare unit was inadequate . ( prison service)
” Open source report
18 Nov 2013 STUART ARRON COLLINS · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 5 Hand sanitiser gel stored within possible patient reach in A&E View source Failure to keep A&E nursing notes complete and up to date View source Failure to record nursing-observation frequency on the A&E whiteboard View source Uncertainty over assessment on arrival at A&E View source Failure to take hourly nursing observations in A&E 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
STUART ARRON COLLINS · 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
Stuart Arron Collins was taken to hospital while intoxicated and fully conscious, but was discharged several hours later with a reduced level of consciousness. After arriving at an address, he became unconscious and suffered cardiorespiratory arrest before being returned to hospital, where he died later that day. Concerns included uncertainty about his assessment on arrival, the absence of required hourly nursing observations, incomplete nursing records, and the possible accessibility of alcohol hand sanitiser gel.
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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Hand sanitiser gel stored within possible patient reach in A&E
Wider context from the report “5. Evidence was given that the hand sanitiser gel was collected from the A&E department. However further evidence was given that the collected hand gels (estimated at 20 in number) were placed on the nurses station very close to Mr Collins’s cubicle . There was contradictory evidence as to whether Mr Collins could have accessed the hand gel from the nurses station .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep A&E nursing notes complete and up to date
Wider context from the report “4. Evidence was given that the nursing notes in A&E were not fully completed and were not kept up to date . There was no apparent recording about Mr Collins’s epilepsy or the need for the hand sanitiser gel to be moved out of his reach .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record nursing-observation frequency on the A&E whiteboard
Wider context from the report “3. Evidence was given that Mr Collins was added to the whiteboard in the A&E dept but that the information regarding the frequency of his nursing observations was not . It was stated that this led to no nursing observations being taken during his first time at A&E on 9.10.12
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty over assessment on arrival at A&E
Wider context from the report “1. There appeared to be a degree of uncertainty as to whether Mr Collins was assessed upon his arrival at the A&E department at James Cook University Hospital ("the hospital")at approx. 00.45 or whether information previously obtained by paramedics was utilised in lieu of an assessment on arrival .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take hourly nursing observations in A&E
Wider context from the report “2. It was stated that Mr Collins should have had hourly nursing observations taken during his first admission to A&E on 9.10.12, ie between 00.45 and his discharge at 04.30, but none were taken .
” Open source report
Concerns raised 4 Delay in scheduling post-discharge nursing follow-up View source Failure to provide an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide View source Failure to communicate the discharge medication safety arrangement to the consultant psychiatrist View source Failure to notify family members of discharge where family support is relevant to safety 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
Linda Hudson · 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
Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after 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 Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in scheduling post-discharge nursing follow-up
Wider context from the report “(3) The deceased was discharged from hospital on the Thursday and no follow up visit from a nurse was scheduled until the following Monday . The Consultant Psychiatrist attending the inquest giving evidence confirmed that this was too long a time taking into account all of the circumstances of the case and a nurse should have made contact with the deceased probably the next day or the Friday though she was unable to say whether this might have made any difference in all the circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an appropriate medication supply and collection arrangement on discharge for a person at risk of self-harm or suicide
Wider context from the report “(1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the discharge medication safety arrangement to the consultant psychiatrist
Wider context from the report “(1) The deceased was discharged from hospital with 3 days prescription of her medication. In the community she had to collect her prescription on a daily basis to reduce the risk of self-harm or suicide. The Consultant Psychiatrist giving evidence at the inquest said that he was unaware of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tees, Esk and Wear Valleys NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify family members of discharge where family support is relevant to safety
Wider context from the report “(2) Upon discharge the hospital did not contact the family to make them aware of her discharge even though family members had visited the deceased whilst in hospital. It may well have been that if the family had contacted the deceased upon her discharge and given support that her death could have been avoided.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations