Recipient

The British Psychological Society

First report 9 Oct 2019•Latest report 9 Oct 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Registered charity. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 3

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from The British Psychological Society linked to the concerns in each report. Select any concern, action or position to view the source wording.

9 Oct2019
Nottinghamshire
Concerns raised3
1. Failure of professionals caring for people with Pica to understand its health risks
2. Lack of national or professional guidance on identification, assessment and management of Pica and its risks
3. Lack of national or professional guidance for monitoring bezoar development in people with Pica
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Write to UK Clinical Psychology training programme directors requesting confirmation that Pica and associated mortality risks are explicitly taught.
  Stated completed
2. Action
  Circulate articles on James’s death and guidance on managing Pica to UK Clinical Psychology training programme directors.
  Stated completed
3. Action
  Actively support development and dissemination of multiprofessional guidelines on managing Pica.
  Stated in progress
AI-generated summary

James Frankish · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

James Frankish died at Beeches Residential Home after vomiting plant material and expelling a hard plant mass from his stomach into his oesophagus, causing sudden obstruction. The principal concerns were that professionals and care staff did not fully understand or manage the dangers of Pica, and that national or professional guidance was lacking on identifying, assessing and managing Pica and monitoring for bezoar development.

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 The British Psychological Society; that does not assign responsibility.
PFD Monitor interpretation
Failure of professionals caring for people with Pica to understand its health risks
Wider context from the report
“(1) Professionals who cared for James did not understand how dangerous Pica can be, ie that it carries significant health risks, including the development of a bezoar. This included the GP, Paediatrician, Psychiatrist, Speech and language therapist, Clinical Psychologist. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Psychological Society; that does not assign responsibility.
PFD Monitor interpretation
Lack of national or professional guidance on identification, assessment and management of Pica and its risks
Wider context from the report
“(2) That there is no national or professional guidance about identification, assessment and management of Pica, with no guidance about how best to understand and manage risk in this condition ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Psychological Society; that does not assign responsibility.
PFD Monitor interpretation
Lack of national or professional guidance for monitoring bezoar development in people with Pica
Wider context from the report
“(3) That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica. ”
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
Write to UK Clinical Psychology training programme directors requesting confirmation that Pica and associated mortality risks are explicitly taught.

Verbatim wording from the response
“In light of your report, I have written personally to the programme directors of every UK Clinical Psychology training programme to ask them to confirm that Pica, and the associated health risks including risk of mortality, are explicitly addressed in teaching on their programme.”

Source location
Response from The British Psychological Society
Page 2 · response
Published 9 October 2019
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
Circulate articles on James’s death and guidance on managing Pica to UK Clinical Psychology training programme directors.

Verbatim wording from the response
“Furthermore, I have also circulated to programme directors two articles written by British Psychological Society member, and Chartered Clinical Psychologist, ████████, together with James’ parents, ████████, on James’ death and guidance on managing Pica, that were published by the National Autistic Society in April 2019 (see attached).”

Source location
Response from The British Psychological Society
Page 2 · response
Published 9 October 2019
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
Actively support development and dissemination of multiprofessional guidelines on managing Pica.

Verbatim wording from the response
“In recent years health and care professionals in the field of intellectual disabilities have set an excellent example of interprofessional working to improve service user outcomes and the British Psychological Society has supported the Learning Disabilities Professional Senate since its inception. We will actively support the development and dissemination of multi-professional guidelines relating the management of Pica.”

Source location
Response from The British Psychological Society
Page 3 · response
Published 9 October 2019
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure of professionals caring for people with Pica to understand its health risks

Lack of national or professional guidance on identification, assessment and management of Pica and its risks

Lack of national or professional guidance for monitoring bezoar development in people with Pica

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.3

Actions described in response 3