Concerns raised 7 Failure of the HTT to obtain a written discharge plan from the hospital View source Failure to liaise with the HTT before discharge View source Failure to formulate a written discharge plan identifying the responsible community HTT View source Failure of the HTT to establish the patient's consent to contact a support person View source Failure to identify a responsible HTT for the discharge address View source Failure to inform the relevant HTT of consent to contact support persons View source Failure to contact consented friends and relatives regarding community support View source See 4 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Anne Morris · 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
Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.
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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure of the HTT to obtain a written discharge plan from the hospital
Wider context from the report “(4) The Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17. Had the HTT made contact with the Priory Hospital it would still have been possible to formulate a plan (including the availability of collateral assistance from Messrs ████████).
” 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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the HTT before discharge
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to 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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a written discharge plan identifying the responsible community HTT
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues.
” 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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure of the HTT to establish the patient's consent to contact a support person
Wider context from the report “(5) The Oxleas HTT do not appear to have been aware of Anne’s willingness for mental health professionals to contact her friend ████████ regarding community support with her suicide risk . Had Oxleas HTT proactively made contact with the Priory Hospital they could have been made aware of this arrangement.
” 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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a responsible HTT for the discharge address
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to 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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant HTT of consent to contact support persons
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues .
” 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 Ticehurst House; that does not assign responsibility.
PFD Monitor interpretation Failure to contact consented friends and relatives regarding community support
Wider context from the report “(1) I am concerned that the staff at the Priory Hospital did not make contact with friends and relatives after Anne had consented to them being contacted .
” Open source report
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