Recipient

The Priory Hospital Roehampton

First report 21 Aug 2017•Latest report 1 Mar 2023

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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 Mar2023
Inner West London
Concerns raised3
1. Failure to contact emergency contacts or next of kin before or at discharge
2. Failure to arrange follow-up appointments before discharge
3. Failure to contact the patient after discharge
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

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
21 Aug2017
Inner West London
Concerns raised4
1. Failure to automatically treat ligature incidents as SIUs
2. Lack of clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger investigation
3. Lack of risk assessment of the East Wing ward configuration over four floors
1. Lack of formal guidance on the frequency of observation competency checklist completion by ad-hoc agency staff
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

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

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

Failure to arrange follow-up appointments before discharge

Failure to contact the patient after discharge

Concerns raised4

Failure to automatically treat ligature incidents as SIUs

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

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

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