21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
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Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams View source See 9 more concerns
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AI-generated summary
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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× 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment policy .
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” 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 University Hospitals Dorset NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” Open source report
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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 Recruit a temporary part-time Band 7 specialist epilepsy nurse for one day per week, supporting transition to adult epilepsy care.
Verbatim wording from the response “In addition, the Trust is currently in the process of recruiting to the epilepsy team a part time 1 day a week Band 7 specialist nurse. This is a temporary post with funding for 12 months. The successful candidate has a long track record of dealing with Children & Young Persons who suffer from epilepsy which will be of great assistance to young people transitioning to adult epilepsy care. Whilst this individual is employed through our bank, we will be reviewing the impact, with the aim of developing a substantive model and funding, as part of the system working through the Integrated Care Board’s review.” Source location Response from NHS Dorset Healthcare University (2)
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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 Appoint and establish a full-time Band 4 epilepsy coordinator role supporting the specialist epilepsy nurses and patient care.
Verbatim wording from the response “I am pleased to inform you that since the Gaia Pope-Sutherland inquest concluded the Trust has appointed a new full time Band 4 epilepsy co-ordinator to the team, who directly supports the two epilepsy specialist nurses. It is anticipated that the successful candidate will commence in post on 1st October 2022. The main duties of this role include:” Source location Response from NHS Dorset Healthcare University (2)
Open published response
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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 Work collaboratively with the Integrated Care Board to assist its review of the epilepsy and neurology service.
Verbatim wording from the response “In relation to your request for consideration of a review of the nursing resources in epilepsy care locally in the Dorset Epilepsy Service, I can confirm that the Integrated Care Board (ICB) are carrying out an 8 week review which started on 11 August 2022. The review team, informed by the Getting It Right First Time (GIRFT) reports for neurology and epilepsy, are looking at the entire Epilepsy and Neurology service. This will be specifically considering:” Source location Response from NHS Dorset Healthcare University (2)
Open published response
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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 Review the impact of the temporary Band 7 specialist nurse post to inform development of a substantive staffing model and funding.
Verbatim wording from the response “In addition, the Trust is currently in the process of recruiting to the epilepsy team a part time 1 day a week Band 7 specialist nurse. This is a temporary post with funding for 12 months. The successful candidate has a long track record of dealing with Children & Young Persons who suffer from epilepsy which will be of great assistance to young people transitioning to adult epilepsy care. Whilst this individual is employed through our bank, we will be reviewing the impact, with the aim of developing a substantive model and funding, as part of the system working through the Integrated Care Board’s review.” Source location Response from NHS Dorset Healthcare University (2)
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for improving communication between neurology and psychiatric teams lies nationally, not with the local Trust.
Verbatim wording from the response “2(ii) Communication between neurology and psychiatric teams” Source location Response from NHS Dorset Healthcare University (2)
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations