Concerns raised 3 Failure of professionals caring for people with Pica to understand its health risks View source Lack of national or professional guidance on identification, assessment and management of Pica and its risks View source Lack of national or professional guidance for monitoring bezoar development in people with Pica View source
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
Action
Write to UK Clinical Psychology training programme directors requesting confirmation that Pica and associated mortality risks are explicitly taught.
View source
Action
Circulate articles on James’s death and guidance on managing Pica to UK Clinical Psychology training programme directors.
View source
Action
Actively support development and dissemination of multiprofessional guidelines on managing Pica.
View source
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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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations