Concerns raised 5 Lack of staff knowledge, skills or training to handle and de-escalate residents entering a road View source Failure of communication processes to escalate a deteriorating patient View source Lack of staff awareness of the nature and extent of resident support duties View source Failure to communicate concerning behaviour and environmental damage to mental health staff View source Lack of communication with the treating mental health team View source See 2 more concerns
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.
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AI-generated summary
Paul Christopher REEVES · 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
Paul Christopher Reeves died in hospital on 9 April 2024 after ingesting and aspirating mud following the use of unknown drugs or psychoactive substances, and suffering a cardiac arrest during re-intubation. The principal concerns related to inadequate communication between his supported accommodation and mental health team, uncertainty about staff responsibilities, escalation of concerns about his deteriorating condition, and staff knowledge, skills or training in responding to his behaviour in the community.
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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge, skills or training to handle and de-escalate residents entering a road
Wider context from the report “4. In the early morning of 28 March 2024 (approximately 07:13), the CCTV footage showed Mr Reeves crawling out of the front entrance to Maygrove Road, initially into the bin area and, a few minutes later, into the road. A support worker from Maygrove Road can be observed walking towards Mr Reeves. However, from the CCTV footage, the support worker appears to make limited attempts, if any, to engage Mr Reeves or block his path into the carriageway of the road . I heard evidence that staff members would not be permitted to restrain Mr Reeves; however, the CCTV footage raises concerns that staff may lack the knowledge, skills or training in handling or attempting to de-escalate a situation such as this . For the avoidance of doubt, there was no evidence that an improved response would have altered the outcome for Mr Reeves, but that does not diminish the future risks to others.
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of communication processes to escalate a deteriorating patient
Wider context from the report “3. Although concerns regarding Mr Reeves’ presentation (para 2 above) were not raised during the telephone call from mental health staff, the manager of Maygrove Road did send an email to Mr Reeves’ care co-ordinator. That email raised health and safety concerns relating to the damage caused by Mr Reeves to his room/flat. However, it did contain phrases such as, ‘he is not doing well’ and he appears ‘very unwell’. I found that an email (essentially headed as a health and safety matter) essentially raised concerns about escalation and communication of a deteriorating patient .
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the nature and extent of resident support duties
Wider context from the report “1. Maygrove Road, the supported accommodation, is not a care home and there is no expectation that staff at the accommodation will administer or supervise medication. Despite this, staff at the accommodation documented that they had collected Mr Reeves’ medication ‘for daily supervision’. Staff were aware that it was an expectation, from the mental health unit, that the accommodation staff should supervise Mr Reeves’ compliance with his medication. There is no suggestion that the accommodation provider contacted the mental health unit to advise that this was something that they were unable to facilitate.
The concerns here are twofold. First, there appeared to be a lack of awareness from staff at Maygrove Road about the nature and extent of what they could/should do to support residents . Second, there was a lack of communication with the treating mental health team.
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerning behaviour and environmental damage to mental health staff
Wider context from the report “2. During a welfare check on Mr Reeves on the morning of 26 March 2024, it was noted that Mr Reeves was ‘agitated’ and that ‘there were broken glasses and pulled electrical panel in his flat’. It was also noted that Mr Reeves ‘didn’t know what had happened’. The mental health unit contacted staff at Maygrove Road on 27 March 2024 and it was accepted in evidence that the concerns about Mr Reeves’ behaviour and the damage caused to his flat were not mentioned to the mental health staff . In the circumstances, these matters not having been raised with the mental health staff deprived the mental health team of an opportunity to assess Mr Reeves’ mental state and leave status , and to consider whether or not he should have remained on leave. The manager at Maygrove Road told me in evidence that they would not expect staff to raise these matters with the mental health team; something which I found to be ‘irrational’.
While I found that there was insufficient evidence to suggest that this would have altered the outcome for Mr Reeves, it raises serious concerns about communication that would enable mental health professionals properly to assess the needs and status of patients in the community, particularly given the accommodation ‘generally supports residents with mental health needs’.
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of communication with the treating mental health team
Wider context from the report “1. Maygrove Road, the supported accommodation, is not a care home and there is no expectation that staff at the accommodation will administer or supervise medication. Despite this, staff at the accommodation documented that they had collected Mr Reeves’ medication ‘for daily supervision’. Staff were aware that it was an expectation, from the mental health unit, that the accommodation staff should supervise Mr Reeves’ compliance with his medication. There is no suggestion that the accommodation provider contacted the mental health unit to advise that this was something that they were unable to facilitate.
The concerns here are twofold. First, there appeared to be a lack of awareness from staff at Maygrove Road about the nature and extent of what they could/should do to support residents. Second, there was a lack of communication with the treating mental health team .
” Open source report
Concerns raised 7 Failure to review relevant historical mental health records View source Failure to distinguish denial of a suicide plan from refusal to answer View source Disjointed coordination of care between crisis house and crisis team services View source Unavailability of mental health records to crisis house staff View source Risk assessment plans failing to be enforceable in an open crisis facility View source Insufficient detail in written risk assessments provided to the crisis house View source Failure to arrange crisis team follow-up meetings View source See 4 more concerns
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
Siân Louise WITHERIDGE · 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
Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.
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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant historical mental health records
Wider context from the report “3. The crisis team staff (as opposed to the crisis house staff) did have access to Ms Witheridge’s mental health records, but they did not read them any further back than the first call to crisis house during that last episode, i.e. 25 May 2017, despite her very extensive past medical history .
There seemed a lack of recognition of the importance of the notes, particularly the older notes .
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish denial of a suicide plan from refusal to answer
Wider context from the report “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan .
False reassurance appeared to have been drawn from the latter . No arrangement was made for the crisis team to meet Ms Witheridge on 30 May.
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Disjointed coordination of care between crisis house and crisis team services
Wider context from the report “6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust .
For example, the crisis team members who gave evidence did not have any knowledge of the crisis house procedure for risk assessing before allowing leave .
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health records to crisis house staff
Wider context from the report “1. While Ms Witheridge was staying in Crisis House, her mental health records were not available to the OneHousing staff there .
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Risk assessment plans failing to be enforceable in an open crisis facility
Wider context from the report “4. One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave.
However, this was an unenforceable plan, because Highbury Grove is an open facility .
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in written risk assessments provided to the crisis house
Wider context from the report “2. I was told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been .
” 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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange crisis team follow-up meetings
Wider context from the report “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.
False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May .
” Open source report
Concerns raised 1 Failure of window stays to be disableable from inside in an emergency View source
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
Frazer Lee George Livesey · 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
Frazer Lee George Livesey died after petrol ignited while he was working on motorcycles in a friend's flat, trapping him inside. He was overcome by fumes, and the principal concern was that window restrictors could not be disabled from inside during an emergency, potentially preventing escape.
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 Riverside Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of window stays to be disableable from inside in an emergency
Wider context from the report “The concern is that the window stays could not be disabled from the inside in an emergency , it is possible the deceased could have survived and his friend suffered less serious injuries if they had been able to escape.
” 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