Recipient

TRU (Transitional Rehabilitation Unit) Ltd

First report 20 Dec 2019•Latest report 20 Dec 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 4

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.

100%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from TRU (Transitional Rehabilitation Unit) Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

20 Dec2019
Manchester (West)
Concerns raised2
1. Failure to invite family members to relevant MDT meetings
2. Failure to inform families and seek their views about decisions to remove a Mental Health Act section
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Revise and implement MH12 Section 117 planning and MH10 family and external communication policies for people detained under the Mental Health Act.
  Stated completed
2. Action
  Revise and introduce the organisation-wide MH28 care planning and care coordination policy, including decision-making, communication, review, transition and discharge tools.
  Stated completed
3. Action
  Provide further training to management teams on the revised care planning and care coordination policy.
  Stated completed
1. Action
  Establish an audit framework and conduct regular reviews to monitor compliance and service delivery across the revised care planning procedures.
  Stated completed
AI-generated summary

David Richard Fowler · 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

David Richard Fowler, who had a significant history of mental illness, substance misuse and a brain injury, died after falling from a motorway bridge on 26 December 2018 with the intention of ending his life. Eight days earlier, his detention under section 3 of the Mental Health Act 1983 was removed without a community plan or legal framework. The report identified concerns that his family was not invited to the relevant meeting or consulted, and that there was confusion about responsibility for informing family members.

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 TRU (Transitional Rehabilitation Unit) Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to invite family members to relevant MDT meetings
Wider context from the report
“In David’s case, no steps were taken to invite ████████ (or any other family member) to the MDT meeting on the 18th December 2018 when the decision was made by the Responsible Clinician to remove David from the confines of section 3 (and section 17) of the Mental Health Act 1983. It is a requirement of the Mental Health Act 1983 that the nearest relative is informed. Further, family views were not sought regarding the decision to lift the section in any other way. At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family. Whilst I was informed that a Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal Policy in place covering contact with families in respect of the above decisions and/or in respect of inviting family members to MDTs more generally. I was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs and of any potential decision to remove a “section”. ”
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 TRU (Transitional Rehabilitation Unit) Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to inform families and seek their views about decisions to remove a Mental Health Act section
Wider context from the report
“In David’s case, no steps were taken to invite ████████ (or any other family member) to the MDT meeting on the 18th December 2018 when the decision was made by the Responsible Clinician to remove David from the confines of section 3 (and section 17) of the Mental Health Act 1983. It is a requirement of the Mental Health Act 1983 that the nearest relative is informed. Further, family views were not sought regarding the decision to lift the section in any other way. At the inquest, staff remained unclear between themselves as to whose responsibility it was to inform the family. Whilst I was informed that a Policy has been drafted and is in the process of being ratified, it remained the case that there was no formal Policy in place covering contact with families in respect of the above decisions and/or in respect of inviting family members to MDTs more generally. I was further concerned that there was on-going confusion between witnesses (in particular the Acting Manager and the Responsible Clinician) as to who is tasked with informing the family of MDTs and of any potential decision to remove a “section”. ”
Open source report
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
Revise and implement MH12 Section 117 planning and MH10 family and external communication policies for people detained under the Mental Health Act.

Verbatim wording from the response
“I have also attached two revised policies specific to care planning policies for adults detained under the Mental Health Act most relevant to this regulation. These are the MH12 Section 117 planning policy and the MH10 Communicating to family and external parties’ policy for people under the Mental Health Act. These two policies outline specifically:”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 2 · response
Published 6 January 2020
Open published response
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
Revise and introduce the organisation-wide MH28 care planning and care coordination policy, including decision-making, communication, review, transition and discharge tools.

Verbatim wording from the response
“There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 1 · response
Published 6 January 2020
Open published response
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 further training to management teams on the revised care planning and care coordination policy.

Verbatim wording from the response
“There has been a comprehensive review of the policies and procedures underpinning critical decision making in care planning including individuals requiring treatment under the Mental Health Act and those being discharged from the Act. This has included a revision of procedures regarding multidisciplinary team communications, mental capacity assessments, care coordination and care planning, communication with family and statutory services and aftercare and discharge planning processes. A revised policy responding to all of the points raised in the Regulation 28 has been completed and introduced with further training to management teams in relation to this. This policy introduced various checklists and tools to be used in practice in accordance with this policy and ensures all relevant processes are followed at each stage of the care planning process.”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 1 · response
Published 6 January 2020
Open published response
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
Establish an audit framework and conduct regular reviews to monitor compliance and service delivery across the revised care planning procedures.

Verbatim wording from the response
“I confirm there have been regular reviews of these procedures since the inquest and an audit framework has been devised to monitor continued compliance and service delivery in these areas including direct audit of the stages outlined in appendix 1.0 (care planning framework).”

Source location
2019-0450-Response-from-Transitional-Rehabilitation-Unit-Redacted
Page 2 · response
Published 6 January 2020
Open published response

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 raised2

Failure to invite family members to relevant MDT meetings

Failure to inform families and seek their views about decisions to remove a Mental Health Act section

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.4

Actions described in response 4