10 Nov 2023 Christopher Richard ALLUM · Prevention of Future Deaths report East Sussex
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Concerns raised 3 Unavailability of NHS notes to private healthcare providers at admission View source Failure to obtain and record previous methods of self-harm and suicide at referral and admission View source Failure to seek and record relevant information from family at referral and admission 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. 6
Action
Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.
View source
Action
Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.
View source
Action
Amend initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.
View source
Action
Require staff to obtain family contact information and speak with next of kin when agreed, recording the information provided.
View source
Action
Provide qualified medical staff with read-only access to referred patients’ NHS medical records.
View source
Action
Amend the initial referral form to require referrers to record previous suicide methods and self-harm methods, with explanations for incomplete information.
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AI-generated summary
Christopher Richard ALLUM · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Richard Allum had escalating mental health issues and a history of deliberate self-harm before being admitted to the Langford Centre on 14 May 2022. He was found unresponsive in his room on the evening of 15 May 2022, and death was confirmed at 23:01; the inquest concluded that he died as a result of suicide. The concerns identified included gaps in obtaining and recording previous methods of self-harm and relevant family information at referral and admission, and difficulties accessing NHS notes in private healthcare settings.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Langford Centre; that does not assign responsibility.
PFD Monitor interpretation Unavailability of NHS notes to private healthcare providers at admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes . It appears to be the position across the private sector that access to an individual's notes is not provided as standard . This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed . This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Langford Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and record previous methods of self-harm and suicide at referral and admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide . There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Langford Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to seek and record relevant information from family at referral and admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission . An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” 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 Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.
Verbatim wording from the response “In order to further explore possible past suicide attempts and to ensure full capture of a patient’s self-harm history at the admission stage, both the initial medical assessment and formation of risk assessment, completed by the triaging doctor at Langford, include the same subsections.” Source location Response from Bramley Health
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 Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.
Verbatim wording from the response “Finally, as there have been amendments to our initial processes, training updates have been rolled out company wide. This includes training to staff who triage our initial referral documents, medical doctors who conduct the initial assessments and consultants who oversee our ward rounds and MDT’s. All staff have been fully informed of the additional processes and the sensitivities surrounding the nature and detail of the information being requested.” Source location Response from Bramley Health
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 Amend initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.
Verbatim wording from the response “b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.” Source location Response from Bramley Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to obtain family contact information and speak with next of kin when agreed, recording the information provided.
Verbatim wording from the response “If agreed, a qualified member of staff is subsequently tasked with reaching out to the family and recording vital information. The document includes a section to record the information provided by a family or relative. Obtaining contact information and speaking with the next of kin are now a mandatory task at Langford.” Source location Response from Bramley Health
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 Provide qualified medical staff with read-only access to referred patients’ NHS medical records.
Verbatim wording from the response “I note that in relation to your further concern relating to difficulties in accessing a patient’s NHS notes, you made reference during your conclusions to the unprecedented steps The Langford” Source location Response from Bramley Health
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 Amend the initial referral form to require referrers to record previous suicide methods and self-harm methods, with explanations for incomplete information.
Verbatim wording from the response “In order to address concerns relevant to The Langford Centre, we have been liaising with SPFT, and the following corrective measures have been agreed with our partners to be implemented from 1st January 2024;” Source location Response from Bramley Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtaining information from an informal patient’s family depends on the patient’s consent.
Verbatim wording from the response “b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.” Source location Response from Bramley Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Referring Trusts or bodies are responsible for completing previous suicide-method information in the initial referral form.
Verbatim wording from the response “a) Our initial referral form has been amended to include an additional field, entitled ‘Previous Suicide Methods’, which must be completed by the referrer. This field includes a supporting sub-section headed ‘Previous Suicide Methods Used,’ which is intended to record details of the self-harm methods.” Source location Response from Bramley Health
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations