The Priory Hospital Roehampton

Health and care · Healthcare site

Pin Request correction

First report 21 Aug 2017•Latest report 1 Mar 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from The Priory Hospital Roehampton linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner West London

    AI-generated summary

    Annabel Jean Findlay · 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

    Annabel Jean Findlay had a history of psychiatric illness and depression and discharged herself from Priory Hospital, Roehampton on 27 August 2021 after a change in antidepressant medication. The concerns identified were that next of kin or emergency contacts were not contacted, no follow-up appointment was booked before discharge, and no attempt was made to contact her until 6 September 2021; the inquest recorded a short-form conclusion of suicide and fatal pressure to the neck as the medical cause 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 The Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to contact emergency contacts or next of kin before or at discharge

    Wider context from the report

    “Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her 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 The Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange follow-up appointments before discharge

    Wider context from the report

    “Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her 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 The Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to contact the patient after discharge

    Wider context from the report

    “Although a discharge plan was implemented in Ms. Findlay’s case, it would appear that steps were not taken to contact her emergency contact and/or next of kin, such as to facilitate Ms. Findlay being supported in the community upon discharge. Ms. Findlay, having discharged herself, left the hospital with next of kin/ emergency contacts not being aware of her discharge – despite, her emergency contact being the person who had transported her to the Priory Hospital. No follow up appointments was made prior to Ms. Findlay’s discharge and no attempts were made to contact her following her discharge until 6 September 2021. A. That no contact was made with next of kin/ emergency contacts prior to, or at the time of her release. B. No follow up appointment was booked prior to Ms. Findlay’s discharge. C. No attempt was made to contact Ms. Findly until 6 September 2021 (some 10 days following her discharge). ”
    Open source report

  2. Inner West London

    AI-generated summary

    Francesca Whyatt · 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

    Francesca Whyatt, who was at known risk from ligatures, was found unconscious with tights around her neck at the Priory Hospital on 25 September 2013 and died in hospital on 28 September 2013. The report identifies concerns about the ward’s four-floor configuration, observation arrangements, control of ligature items, staffing and training, and the lack of clear criteria for investigating ligature and other self-harming incidents as serious untoward incidents.

    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 Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to automatically treat ligature incidents as SIUs

    Wider context from the report

    “(3) Ligature incidents are not automatically treated as SIUs (though the evidence suggests that death can occur within seconds of a ligature being applied). ”
    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 Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger investigation

    Wider context from the report

    “(4) There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation. ”
    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 Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of risk assessment of the East Wing ward configuration over four floors

    Wider context from the report

    “(1) There has been no risk assessment of the configuration of the East Wing ward over four floors. ”
    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 Priory Hospital Roehampton; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal guidance on the frequency of observation competency checklist completion by ad-hoc agency staff

    Wider context from the report

    “(2) There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist. ”
    Open source report
Back to top

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