5 Feb 2026 Kallum Josh REED · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure of mental health professionals to work collaboratively to find a safe crisis-care solution View source Unacceptably long waits for ASD and ADHD referrals, assessments and diagnoses View source No route to access halfway-house care except via the crisis team View source Crisis team gatekeeping and rejection of referrals for crisis care View source See 1 more concern
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AI-generated summary
Kallum Josh REED · 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
Kallum Josh REED died after being found fully suspended during a police search following his disappearance on 11 February 2025. The report raises concerns about delays in autism spectrum disorder and ADHD referrals, assessments and diagnoses, and about crisis-care referral pathways and coordination between 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health professionals to work collaboratively to find a safe crisis-care solution
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service, notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued. The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution . The situation appears not to have changed in the 12 months following this death .
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unacceptably long waits for ASD and ADHD referrals, assessments and diagnoses
Wider context from the report “(1) The first concern is the "unacceptably long wait" for referrals, assessments and diagnoses of ASD and ADHD . The court was told that demand is continuing to outstrip the services ability to cope ; services are outsourced to private providers but there are still unacceptable delays . This impacts the provision of care, the provision of appropriate medication, providing the individuals with insight and understanding of their own presentations and the provision of professional support. In Kallum's case this contributed to the factors that caused his death. I am therefore raising this concern with the Minister for the DHSC and the WLNHS Trust
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation No route to access halfway-house care except via the crisis team
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service, notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued. The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. The situation appears not to have changed in the 12 months following this death.
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Crisis team gatekeeping and rejection of referrals for crisis care
Wider context from the report “(2) The second concern is that the court was told that the "crisis team" gate-keep referrals into their service , notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments. The care planning in Kallum's case advised him to contact the single point of access (who had rejected referral back to the crisis team in the weeks preceding the death), to present to ED (which he did but was discharged home to remain under the community team).
The pathways essentially failed as the crisis team still able to reject the referral, thus effectively closing down an avenue for ongoing close care and communication as the crisis presentation continued . The Trust's internal report concluded that Kallum should have been assessed in person and probably should have been accepted back by the crisis team, but in court this conclusion was contested by the service manager. His evidence was that the crisis team was not appropriate for Kallum and the community team should continue the care. This re-emphasised the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. The situation appears not to have changed in the 12 months following this death.
There appears to be no route to access the "half way house" provisions of care unless via the crisis team and so these were not offered or discussed with Kallum or his family who were trying to care for him.
I am therefore raising this concern with the WLNHS Trust
” 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 Monitor delivery and waiting lists through robust monitoring and quality-assurance measures.
Verbatim wording from the response “Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we” Source location 2026-0061 - Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot trusted assessments for Ealing referrals to the crisis, assessment and home treatment team.
Verbatim wording from the response “As part of the work flowing from this reorganisation, and to maximise benefits arising from this organisational change, the Trust decided that integrated pathways and whole person care would be a key element of the Trust Quality Priorities for 2025-2028 (supporting a refreshed Clinical Strategy). As part of this work and directly linked to your” Source location 2026-0061 - Response from West London NHS Trust
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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 Commission additional private-provider capacity for adult autism diagnostic assessments.
Verbatim wording from the response “Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we” Source location 2026-0061 - Response from West London NHS Trust
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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 Clinical Lead to support trusted-assessment changes and improvements across the relevant Ealing services.
Verbatim wording from the response “To fully support this roll-out, we have adjusted the management portfolios in Ealing and brought the Psychiatry Liaison and CAHTT teams together under a single new senior manager with previous experience of working within a trusted assessment framework. We have also recruited a new Clinical Lead who will work across the same portfolio to support the new service manager and implement all necessary changes and improvements supporting the medical staff. This interface and smooth transition remain a priority for the Clinical and Associate Directors within the borough.” Source location 2026-0061 - Response from West London NHS Trust
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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 Bring Ealing Psychiatry Liaison and crisis teams under a single senior manager.
Verbatim wording from the response “To fully support this roll-out, we have adjusted the management portfolios in Ealing and brought the Psychiatry Liaison and CAHTT teams together under a single new senior manager with previous experience of working within a trusted assessment framework. We have also recruited a new Clinical Lead who will work across the same portfolio to support the new service manager and implement all necessary changes and improvements supporting the medical staff. This interface and smooth transition remain a priority for the Clinical and Associate Directors within the borough.” Source location 2026-0061 - Response from West London NHS Trust
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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 Agree with commissioners that adult autism assessment capacity will be augmented.
Verbatim wording from the response “have also now agreed with commissioners that the previously commissioned service was insufficient and will be augmented. The commitment of our commissioners to expand the service will be critical if we are to deliver shorter waiting times on a sustainable footing.” Source location 2026-0061 - Response from West London NHS Trust
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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 Streamline and improve internal adult autism assessment pathways.
Verbatim wording from the response “Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we” Source location 2026-0061 - Response from West London NHS Trust
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 Implement a borough-based mental-health service structure to support integrated, less fragmented care.
Verbatim wording from the response “From April 2025, the Trust moved from a service-line to a borough-based structure. This means that all mental health services are now managed within the borough rather than the previous model which saw all inpatient, all community, all liaison and talking therapies teams managed across the three directorates based on functional similarities. This change ensures that the organisation’s structure better supports integration of care and aims to reduce fragmentation for individuals whose care pathways previously spanned multiple service lines. The new structure supports more joined-up working within boroughs and stronger relationships with partners (both internal and external to the organisation) in place-based systems within the local areas.” Source location 2026-0061 - Response from West London NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adult ADHD assessments are outside the Trust’s commissioned remit, so it cannot respond on this matter.
Verbatim wording from the response “The Trust is not the commissioned provider for adult ADHD assessments in any of our boroughs and therefore cannot respond on this matter. This would best be addressed to the NW London Integrated Care Board as the commissioner.” Source location 2026-0061 - Response from West London NHS Trust
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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 adult ADHD assessments rests with the North West London Integrated Care Board as commissioner.
Verbatim wording from the response “The Trust is not the commissioned provider for adult ADHD assessments in any of our boroughs and therefore cannot respond on this matter. This would best be addressed to the NW London Integrated Care Board as the commissioner.” Source location 2026-0061 - Response from West London NHS Trust
Open published response
19 Jan 2024 Tom Sweeting · Prevention of Future Deaths report West London
View report summary
Concerns raised 7 Inappropriate delegation of family collateral information gathering View source Ineffective communication between community teams View source Failure to communicate treatment plans effectively to patients View source Lack of auditing of training, templates and supervision effectiveness View source Failure to complete the mental health assessment template View source Failure to dispatch liaison psychiatry discharge letters promptly View source Mismatch between junior practitioner training expectations and senior practitioner work practices View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tom Sweeting · 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
Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate delegation of family collateral information gathering
Wider context from the report “3. It was acknowledged that obtaining collateral information from the family is vital , but in this case was delegated to a very Junior member of the team who was in the early stages of her training . It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between community teams
Wider context from the report “2. No letter of discharge was sent at the time Tom was seen by the liaison psychiatry team, and a letter was only generated in response to investigations taking place after the death. The team acknowledged that there were “problems” with sending out letters at the time, and no evidence was brought before the court that this issue has now been resolved. Letters should be dispatched within 24 hours of attendance. Communication between the various community teams and setting out the treatment plan to the patient are important factors that were not effective during Tom’s care and remain a concerning omission where there may be a simple and effective remedy.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate treatment plans effectively to patients
Wider context from the report “2. No letter of discharge was sent at the time Tom was seen by the liaison psychiatry team, and a letter was only generated in response to investigations taking place after the death. The team acknowledged that there were “problems” with sending out letters at the time, and no evidence was brought before the court that this issue has now been resolved. Letters should be dispatched within 24 hours of attendance. Communication between the various community teams and setting out the treatment plan to the patient are important factors that were not effective during Tom’s care and remain a concerning omission where there may be a simple and effective remedy.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of training, templates and supervision effectiveness
Wider context from the report “4. The Trust showed good intentions of reviewing the training programme, but were unable to evidence that planned 6 monthly audits had actually taken place , and so there was no evidence before the court that the new training that had arisen from the serious incident findings was effective. Introducing new training, templates and supervision performance appraisals all seem to be positive interventions, but in the absence of any process to audit their effectiveness , it is concerning that the Trust have no way in which to judge their impact .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the mental health assessment template
Wider context from the report “1. Tom was assessed in relation to his mental ill health presentation by the Consultant liaison psychiatrist, but the Trust template was not completed , which was not in compliance with the Trust policy and criticised in the Trust serious incident report. There is a concerning mismatch of what more junior colleagues are expected to do and be trained in, compared with Senior practitioners demonstrated work practises.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to dispatch liaison psychiatry discharge letters promptly
Wider context from the report “2. No letter of discharge was sent at the time Tom was seen by the liaison psychiatry team , and a letter was only generated in response to investigations taking place after the death. The team acknowledged that there were “problems” with sending out letters at the time , and no evidence was brought before the court that this issue has now been resolved . Letters should be dispatched within 24 hours of attendance. Communication between the various community teams and setting out the treatment plan to the patient are important factors that were not effective during Tom’s care and remain a concerning omission where there may be a simple and effective remedy.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Mismatch between junior practitioner training expectations and senior practitioner work practices
Wider context from the report “1. Tom was assessed in relation to his mental ill health presentation by the Consultant liaison psychiatrist, but the Trust template was not completed, which was not in compliance with the Trust policy and criticised in the Trust serious incident report. There is a concerning mismatch of what more junior colleagues are expected to do and be trained in, compared with Senior practitioners demonstrated work practises .
” 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 Incorporate learning from the incident into teaching for future trainees rotating through liaison psychiatry settings.
Verbatim wording from the response “The Trust shares your concern about the perceived mismatch between senior practitioners’ work practices and expectations of junior colleagues, and since this incident has confirmed that all members of staff received the same training and are expected to adhere to the same policies. Whilst it is normal practice in most healthcare settings for certain aspects of documentation and assessment to be delegated across the multidisciplinary team, including to trainee doctors, the supervising consultant retains responsibility for ensuring adequate supervision. Learning from this event has been incorporated into the teaching plan for future trainees rotating through LPS settings, and will be reflected upon by the senior practitioners involved in their monthly management meetings and annual appraisal.” Source location Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a service-wide tri-borough protocol for GP letters.
Verbatim wording from the response “This project significantly improved the problem of timely GP correspondence, however the risk of recurrence is not entirely eliminated. Therefore, in light of this Coroner inquest the service is initiating a 3-pronged response to fully address on-going systemic obstacles to timely communication with primary care. GP correspondence is now monitored by the senior management team on a daily basis, is a standing item in the team governance meeting and monitored in the service-wide governance meeting. This will constitute the basis of a new service-wide tri-borough protocol for GP letters, which the LPS service and Clinical Lead are jointly developing as part of our response to this inquest. Since the implementation of the protocol, HLP has achieved 97.1% of letters sent within one working day between 20/02/2024 and 05/03/2024.” Source location Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reflect learning from the incident in senior practitioners’ monthly management meetings and annual appraisals.
Verbatim wording from the response “The Trust shares your concern about the perceived mismatch between senior practitioners’ work practices and expectations of junior colleagues, and since this incident has confirmed that all members of staff received the same training and are expected to adhere to the same policies. Whilst it is normal practice in most healthcare settings for certain aspects of documentation and assessment to be delegated across the multidisciplinary team, including to trainee doctors, the supervising consultant retains responsibility for ensuring adequate supervision. Learning from this event has been incorporated into the teaching plan for future trainees rotating through LPS settings, and will be reflected upon by the senior practitioners involved in their monthly management meetings and annual appraisal.” Source location Response from West London NHS Trust
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 Introduce secondary induction training requiring demonstration, observation and supervised practice for collateral-information gathering.
Verbatim wording from the response “The Trust has reviewed this practice, and whilst the collating of collateral information will remain an important training task for junior members of staff, that there was a shortfall in supervision in this instance and improvements were required in the expectation of how the task should be undertaken. To aid with this, a secondary induction programme into the service has been introduced for new staff, which sets out how this task will be demonstrated, and observed before carried out independently with supervision. The service has commissioned a piece of co-development work with our Experts by Experience as Carers representatives to improve the practices further.” Source location Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement automated templates and secure-email processes for timely mental-health correspondence to general practitioners.
Verbatim wording from the response “An automated letter template has been developed, which auto-populates with information pulled from the electronic record, to simplify clinicians’ work when completing these letters. A more robust GP communication process was implemented to send letters to GP practices via secure emails, to eliminate postal delays, with other copies sent by post.” Source location Response from West London NHS Trust
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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 Monitor GP correspondence through daily senior-management checks and governance meetings.
Verbatim wording from the response “This project significantly improved the problem of timely GP correspondence, however the risk of recurrence is not entirely eliminated. Therefore, in light of this Coroner inquest the service is initiating a 3-pronged response to fully address on-going systemic obstacles to timely communication with primary care. GP correspondence is now monitored by the senior management team on a daily basis, is a standing item in the team governance meeting and monitored in the service-wide governance meeting. This will constitute the basis of a new service-wide tri-borough protocol for GP letters, which the LPS service and Clinical Lead are jointly developing as part of our response to this inquest. Since the implementation of the protocol, HLP has achieved 97.1% of letters sent within one working day between 20/02/2024 and 05/03/2024.” Source location Response from West London NHS Trust
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 Provide regular clinical supervision to monitor the quality of clinicians’ work.
Verbatim wording from the response “The service governance structures in place to share learning through a Service Line Quality and Performance meeting into the borough team based Clinical Improvement Groups which are documented. A quarterly Mortality and Morbidity meeting has been introduced for liaison psychiatry teams to reflect on and learn from incidents. In addition, learning from our incidents is now fed into an annual team development programme, in the form of a thematic review of serious incidents, teaching and a complex case discussion forum. All clinicians receive regular clinical supervision which monitors the quality of work individual clinicians conduct.” Source location Response from West London NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delegating aspects of documentation and assessment to trainee doctors remains appropriate where the supervising consultant ensures adequate supervision.
Verbatim wording from the response “The Trust shares your concern about the perceived mismatch between senior practitioners’ work practices and expectations of junior colleagues, and since this incident has confirmed that all members of staff received the same training and are expected to adhere to the same policies. Whilst it is normal practice in most healthcare settings for certain aspects of documentation and assessment to be delegated across the multidisciplinary team, including to trainee doctors, the supervising consultant retains responsibility for ensuring adequate supervision. Learning from this event has been incorporated into the teaching plan for future trainees rotating through LPS settings, and will be reflected upon by the senior practitioners involved in their monthly management meetings and annual appraisal.” Source location Response from West London NHS Trust
Open published response
6 Jul 2023 Mr Oleg Khala · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Unavailability of care-coordinators when needed View source Failure to resolve differing psychiatric team assessments before discharge View source Failure to discuss CATT discharge and admission patients with the on-call psychiatrist View source Unavailability of neurodevelopmental disorder expertise within MINT View source Inadequate recording of patients' mental health history by CATT View source Failure to select the best treatment plan for individual patients, including appropriate admission View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Oleg Khala · 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
Mr Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of care-coordinators when needed
Wider context from the report “3. That the provision of care-coordinators be increased and improved so that patients who require them have ready access at the time of need and are not placed on a waiting list .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve differing psychiatric team assessments before discharge
Wider context from the report “5. That where psychiatric teams differ in their assessments such as CATT and psychiatric liaison , as occurred here, patients are not discharged until opinion is soft from the on-call consultant and re-discussion taken place between those with differing views .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss CATT discharge and admission patients with the on-call psychiatrist
Wider context from the report “4. That patients to be discharged by CATT, as well as patients to be admitted are discussed with the on-call psychiatrist so that plans may be reviewed, and thus the risk of not admitting patients who would benefit from and/ or require admission such as Mr Khala, are less likely to be discharged inappropriately .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of neurodevelopmental disorder expertise within MINT
Wider context from the report “6. That expertise covering neurodevelopmental disorders such as ASD and ADHD is available as part of MINT .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of patients' mental health history by CATT
Wider context from the report “1. The generic, tick-box style of history recording by CATT which does not paint a full and proper picture of the mental health of the patient , especially compared to the assessments of psychiatric liaison, are such that risk may be unrecorded and under appreciated by CATT and patients thus be put at risk.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to select the best treatment plan for individual patients, including appropriate admission
Wider context from the report “2. That the role of CATT to look for alternatives to admission may risk CATT discharging patients who would benefit from admission and risk the repeat of making treatment plans that had recently failed such as in this case. Rather than looking for admission alternatives being a core function, should CATT rather better be focussed on the best treatment plan for the individual patient and thus admission being viewed as a clear option where appropriate rather a last resort, as it often appears to be presented in such cases before the coroner?
” 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 Deploy enhanced documentation practices to support coordinated care.
Verbatim wording from the response “As part of the implementation of this we have developed and are deploying standardized protocols, enhanced documentation practices, and regular training sessions to promote effective coordinated care by any named clinician involved in patient care. These measures aim to mitigate potential risks and ensure that patients receive the highest quality of care in a coordinated manner.” Source location Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the Autism Liaison Service to Ealing MINT and, subject to success, other boroughs and 16–25 teams.
Verbatim wording from the response “In terms of specialised ASD support in West London NHS Trust, Acute Mental Health Services benefits from an Autism Liaison Service which can be contacted for consultative input for any service users with a diagnosis of Autism. Plans are in place to further expand this service for service users within Ealing MINT with a diagnosis of autism or suspected autism, with a view of this being rolled out to other boroughs, if successful. This will also involve consultative input to 16-25 teams.” Source location Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a local commissioned pathway for ADHD assessment and intervention with North West London ICB.
Verbatim wording from the response “WLT is in discussion with North West London ICB to develop a local commissioned pathway for ADHD assessment and intervention.” Source location Response from West London NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with North West London partners to implement clinical escalation protocols for clinical disagreement.
Verbatim wording from the response “Where a joint assessment and decision is not possible, the person(s) completing the assessment will communicate and discuss and agree the findings with the referrer, service user and within the multi-disciplinary team (MDT) handover, which involves consultants. The availability of in-hours and on-call psychiatric registrar (approved under section 12 of the Mental Health Act) and consultant) to provide guidance or supplementary assessment in the event of clinical disagreement has been re-communicated to teams, and will be incorporated into work we are doing with partners across North West London to implement clinical escalation protocols.” Source location Response from West London NHS Trust
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 Embed trusted-assessment working between CATT and Psychiatric Liaison teams for joint admission and home-treatment decisions.
Verbatim wording from the response “The Clinical Directors, Service Managers, Clinical Leads and Team Managers responsible for CATT and Psychiatric Liaison are in regular discussion about interface matters between their services and cases of concern are reviewed regularly. All are in agreement that it is best practice for assessments to take place and decisions to be made jointly wherever possible, and work is ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to admit to beds or home-based treatment pathways under CATT.” Source location Response from West London NHS Trust
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 Remind crisis-assessment staff that they may request senior consultant discussion regardless of the proposed disposition.
Verbatim wording from the response “CATT team members (and other non-medical and trainee medical staff undertaking assessments of patients in crisis) have been reminded that they can request senior discussion with On-call Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway or to discharge.” Source location Response from West London NHS Trust
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 Deploy standardized MINT coordinated-care protocols for named clinicians.
Verbatim wording from the response “Within the MINT model of care, we aim to support individuals who require long term mental health support with coordinated care by a named clinician, and that this clinician is appropriately skilled to provide the interventions recommended in the conducted care plan. We also recognise (in line with the national specification for community mental health services, upon which MINT teams have been designed) that some individuals will receive ‘care coordination’ for only a time limited period in line with their needs.” Source location Response from West London NHS Trust
Open published response
×
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 ADHD assessment and treatment are not commissioned or provided by the Trust.
Verbatim wording from the response “ADHD assessment and treatment is not commissioned or provided as part of the West London Trust.” Source location Response from West London NHS Trust
Open published response
×
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 GPs are responsible for referring service users directly to other ADHD providers when assessment thresholds are met.
Verbatim wording from the response “Service users of the boroughs of Ealing, Hammersmith and Fulham and Hounslow are referred to other services commissioned by North West London Integrated Care Board. They offer diagnosis and treatment for adults with ADHD. Once treatment is stabilised, prescribing and monitoring will be transferred back to the GP. They currently do not offer psychological interventions for the treatment of ADHD in our clinic. The wait time for assessment is currently 18-24 months. GP’s are responsible for making ADHD referrals directly to the other providers if they believe the service user meets the threshold for assessment and on completion of a screening assessment.” Source location Response from West London NHS Trust
Open published response
×
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 North West London Integrated Care Board-commissioned services provide ADHD assessment and treatment for eligible service users.
Verbatim wording from the response “Service users of the boroughs of Ealing, Hammersmith and Fulham and Hounslow are referred to other services commissioned by North West London Integrated Care Board. They offer diagnosis and treatment for adults with ADHD. Once treatment is stabilised, prescribing and monitoring will be transferred back to the GP. They currently do not offer psychological interventions for the treatment of ADHD in our clinic. The wait time for assessment is currently 18-24 months. GP’s are responsible for making ADHD referrals directly to the other providers if they believe the service user meets the threshold for assessment and on completion of a screening assessment.” Source location Response from West London NHS Trust
Open published response
15 Nov 2022 Ronald Alfred KELLY · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Lack of automatic follow-up for patients discharged home who may need support and care View source Failure to action appropriate referrals for district nurse visits and assessments 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
Ronald Alfred KELLY · 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
Ronald Alfred KELLY, aged 91, was found hanging on 19 September 2022 after recently being discharged from hospital and struggling to cope. The concerns included his discharge following surgery without a care package or follow-up, a rejected district nurse referral that was not actioned, and the apparent absence of a system for automatically following up patients discharged home who may need support and care. The inquest concluded that Mr Kelly died from suicide.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic follow-up for patients discharged home who may need support and care
Wider context from the report “1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping .
2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first”. The GP forwarded the referral but nothing was actioned.
3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to action appropriate referrals for district nurse visits and assessments
Wider context from the report “1. That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping.
2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse it was rejected on the basis that the appropriate referral was to “home first” . The GP forwarded the referral but nothing was actioned.
3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up.
” Open source report
24 Jun 2022 ZSOLT KIRJAK · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Insufficient suicide risk assessment View source Lack of enquiry into previous self-harm and associated injury View source Incomplete psychiatric assessment View source Failure to provide the patient's wife an opportunity to contribute to clinical and risk assessments and management planning View source Failure of treatment planning to manage patient risks 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.
×
AI-generated summary
ZSOLT KIRJAK · 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
ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient suicide risk assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide . The treatment plan prescribed did not manage the Patient’s risks.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of enquiry into previous self-harm and associated injury
Wider context from the report “3. There was a lack of enquiry by any of the clinicians who had seen the patient into the Patient’s previous attempt to give himself a stroke and a subsequently acquired eye injury. It is very unusual for a patient to attempt to give oneself a stroke and would reasonably be expected to warrant a detailed assessment because it implies a high degree of harm and lethality.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete psychiatric assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide. The treatment plan prescribed did not manage the Patient’s risks.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the patient's wife an opportunity to contribute to clinical and risk assessments and management planning
Wider context from the report “4. Though there was contact between the LPS clinician and the Patient’s wife, there is no evidence as to whether the Patient’s wife was given the opportunity to contribute to his clinical and risk assessments and corresponding management plan .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of treatment planning to manage patient risks
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially with regards to his psychiatric history (including previous attempts at self harm and the documented recent attempt by the patient to give himself a stroke), substance use and medical history. Correspondingly, there was an insufficient risk assessment that did not include or appraise the Patient’s risk factors for suicide. The treatment plan prescribed did not manage the Patient’s risks.
” Open source report
7 Jun 2022 Mena Tekloe Marim Teferi · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Insufficient capacity and resources to meet mental health service demand 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
Mena Tekloe Marim Teferi · 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
Mena Tekloe Marim Teferi died by suicide at home on 10 October 2021, after being referred to a mental health service but not seen or contacted before her death. The service was described as critically under-resourced, with demand substantially exceeding capacity and resulting in failures to meet service obligations.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity and resources to meet mental health service demand
Wider context from the report “The mental health services went through a transformation process during the Covid pandemic. It became apparent that the anticipated level of direct referrals to the service from primary care was many times in excess of those predicted. The expectation was 6 per day, at the peak this rose to 30 and has currently reduced to 13-14 daily, so remains over 100% above the anticipated level.
The inquest was advised that the service was failing to meet the service demands due to insufficient capacity . The decision was made to enter this onto the Trust’s risk register, and this remains the situation. The critical features remain a high demand for services and a lack of resources .
This court has been told on many occasions that there is an intention for “parity” of mental health services with physical health services, but this is not apparent and the service is unable to meet its obligations now or going forward . This is greater than a “long waiting list” issue and is not a situation that can be explained exclusively by the covid pandemic. A more significant risk to individuals requiring mental health services has now arisen than existed before the transformation programme; it creates a real concern that lives will be lost as a consequence, and no solution was offered to the court during the inquest. The service is set up to deal with less than half of the referrals that it receives, leading to inevitable failings that currently cannot be rectified .
” Open source report
11 Feb 2021 Valeria Munoz Biggs · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 12 Use of inappropriate personal comments when supporting patients View source Lack of staff training in record keeping and updating View source Culture of risk taking in relation to suicidality View source Failure to consider appropriate admission View source Failure to assess suicide risk during the current treatment episode View source Failure to treat patients in line with BNF guidance View source Unsafe operational ethos of the care in the community approach View source Lack of staff training in engaging with and supporting families and carers View source Lack of staff training in suicide risk assessment View source Failure to adhere to treatment plans and planned visiting schedules View source Failure to provide early and ongoing in-person assessment by a fully qualified psychiatrist View source Failure to train staff to consider the views of other qualified psychiatrists View source See 9 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
Valeria Munoz Biggs · 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
Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of inappropriate personal comments when supporting patients
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient , how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in record keeping and updating
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Culture of risk taking in relation to suicidality
Wider context from the report “1. That the Trust has a culture of risk taking in relation to suicidality .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider appropriate admission
Wider context from the report “3. That where appropriate admission should be considered to diagnose, and treat the patient and manage risk of self-harm.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess suicide risk during the current treatment episode
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to treat patients in line with BNF guidance
Wider context from the report “4. That patients should be treated in line with BNF guidance .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe operational ethos of the care in the community approach
Wider context from the report “8. That this case seriously calls into question the operational ethos of the care in the community approach in West London .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in engaging with and supporting families and carers
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers , not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers , that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in suicide risk assessment
Wider context from the report “2. That the Trust staff need training in relation to assessment of suicide risk , how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to treatment plans and planned visiting schedules
Wider context from the report “7. That treatment plans and specifically visiting schedules should not be deviated from , such that planned visits take place unless there is a clinical indication to do so .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide early and ongoing in-person assessment by a fully qualified psychiatrist
Wider context from the report “5. That patients should be assessed in person by a fully qualified psychiatrist early on and during a treatment phase of illness of this potential seriousness .
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train staff to consider the views of other qualified psychiatrists
Wider context from the report “6. That the Trust staff should be trained to consider the views of other qualified psychiatrists with knowledge of a patient .
” Open source report
15 Oct 2019 Matthew George Kaliniecki WILLIAMSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Failure of mental health providers to maintain clear inter-provider coordination View source Lack of opportunity for carers and family members to provide pertinent information to clinical mental health teams View source Absence of a patient roadmap for access to and type of treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew George Kaliniecki WILLIAMSON · 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
Matthew was found locked in a bathroom and had hung himself using a dressing gown cord attached to a wall-mounted radiator, resulting in his death at the scene on 24 October 2018. The report raises concerns about limited opportunities for carers and family members to provide information to mental health teams and unclear coordination between mental health providers, making access to appropriate treatment difficult.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health providers to maintain clear inter-provider coordination
Wider context from the report “There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear . This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of opportunity for carers and family members to provide pertinent information to clinical mental health teams
Wider context from the report “There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear. This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a patient roadmap for access to and type of treatment
Wider context from the report “There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear. This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment .
” 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 Amend operational policies to strengthen family involvement, manage cases where consent is withheld, and adopt Triangle of Care principles.
Verbatim wording from the response “• Amendment of operational policies to include sections on strengthening family involvement; managing cases where consent is not given; and the adoption of the Triangle of Care.” Source location 2019-0349-Response-from-West-London-NHS-Trust-Redacted
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 Implement Triangle of Care standards across Trust services and submit regular progress reports to the Carers Trust.
Verbatim wording from the response “21. The Trust is a formal member of the ‘Triangle of Care’ membership scheme, and we have committed to implementing the standards set out in the ‘Triangle of Care’. Part of this includes submitting regular progress reports to the Carers Trust. Progress reports for each stage of implementing the ‘Triangle of Care’ (Stage 1 and Stage 2) are expected. At West London NHS Trust, ‘Stage 1’ is the roll out of self-assessments throughout our inpatient services and crisis teams, and ‘Stage 2’ is the roll out of self-assessments throughout community services. We are currently considering whether a further stage is required for our community physical health services.” Source location 2019-0349-Response-from-West-London-NHS-Trust-Redacted
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 Operate the Trust Single Point of Access to process referrals and provide 24/7 mental health support and signposting.
Verbatim wording from the response “9. Specifically, as it is often GPs who will see patients with a range of mental health difficulties and who will then refer patients needing mental health services, we have established the Trust Single Point of Access (SPA) to support both GP referrals, and to help signpost people in need who have chosen not to see a GP, or who are unable to see a GP.” Source location 2019-0349-Response-from-West-London-NHS-Trust-Redacted
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 Ealing Primary Care Mental Health Service staff with Carer Awareness and Triangle of Care training.
Verbatim wording from the response “• Ealing PCMHS staff must attend Carer Awareness and Triangle of Care training sessions.” Source location 2019-0349-Response-from-West-London-NHS-Trust-Redacted
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 Transform community services into integrated primary and secondary mental health teams aligned with Primary Care Networks and remove service boundaries.
Verbatim wording from the response “17. As a result of this new framework, West London NHS Trust services are in the process of transforming to a series of integrated primary and secondary mental health teams, wrapped around the Primary Care Networks. Our new service will offset the need for criteria to be met to access a more intensive input at times of increased mental health need, and will ensure that boundaries between services are removed.” Source location 2019-0349-Response-from-West-London-NHS-Trust-Redacted
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 Strengthen managerial, clinical and carer support for embedding Triangle of Care practices in day-to-day work.
Verbatim wording from the response “24. In order to continue towards Stage 2 and beyond, the Trust has identified the following areas for development:” Source location 2019-0349-Response-from-West-London-NHS-Trust-Redacted
Open published response
4 Nov 2018 PATRICIA PRISCILLA CHAMBERS · Prevention of Future Deaths report West London
View report summary
Concerns raised 9 Failure of the Care Programme Approach to comply with the Code of Practice View source Inadequate record keeping in the Practice View source Failure to communicate the Discharge Medication Summary to relevant parties View source Failure of the Discharge Medication Summary and 7-Day Follow-Up to provide an adequate format View source Unsatisfactory Practice information collection, recording, saving and dissemination system View source Failure of the Discharge Medication Summary to be consistent with the Care Programme Approach Policy View source Inadequate training of Primary Nurses View source Inadequate supervision of Primary Nurses View source Inadequate appointment of Primary Nurses View source See 6 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
PATRICIA PRISCILLA CHAMBERS · 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
Patricia Chambers died by suicide on 11 May 2016 after jumping from the ninth-floor communal walkway of her residence, sustaining non-survivable injuries. The inquest identified deficiencies in her mental-health discharge process, communication and continuity of care, as well as inadequate GP record keeping and document control; the report remained concerned that information could be lost or ignored and pose a risk to future deaths.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Care Programme Approach to comply with the Code of Practice
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate record keeping in the Practice
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016 , and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the Discharge Medication Summary to relevant parties
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Discharge Medication Summary and 7-Day Follow-Up to provide an adequate format
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsatisfactory Practice information collection, recording, saving and dissemination system
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory , and that this could lead to information being lost and/or ignored , with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Discharge Medication Summary to be consistent with the Care Programme Approach Policy
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of Primary Nurses
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of Primary Nurses
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate appointment of Primary Nurses
Wider context from the report “I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of:
- The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn
- Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy)
- Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review)
- Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice)
- The appointment, training and supervision of the role of Primary Nurse on the Ward.
The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death.
In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax.
However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered.
I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken.
” Open source report
25 Oct 2016 Nihad Ousta · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Lack of written guidance or policy for management of head injury 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
Nihad Ousta · 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
Nihad Ousta was admitted to a mental health ward and suffered visible head trauma on two occasions before deteriorating and undergoing neurosurgical treatment. He was later transferred to a nursing home and then admitted to St George’s Hospital, where he died several months later. The report identified the absence of written guidance or a protocol for managing head injuries, including the frequency and range of general and neurological observations.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written guidance or policy for management of head injury
Wider context from the report “There was not and currently is not a protocol or other written guidance or policy for the management of head injury (to include frequency and range of general and neuro observations)
” Open source report
9 Mar 2015 Darren Linfoot · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3 Inconsistent understanding of radio nurse duties on the admissions ward View source Inconsistent methods for performing four-hourly patient observations View source Failure to audit and monitor non-controlled potent medication 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
Darren Linfoot · 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
Darren Linfoot was found unresponsive in his room at Broadmoor Hospital on 18 December 2011 and was declared deceased at Frimley Park Hospital. A post-mortem examination found lobar pneumonia as the cause of death, with dihydrocodeine toxicity contributing. Concerns included inadequate auditing of some potent medications, inconsistent four-hourly patient observations, and inconsistent understanding of the radio nurse’s duties.
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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of radio nurse duties on the admissions ward
Wider context from the report “(3) Nursing staff also gave inconsistent evidence about the duties of the radio nurse on the admissions ward. There appeared to be a need for consistency and appropriate training.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent methods for performing four-hourly patient observations
Wider context from the report “(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations . It is suggested that a consistent method is identified and appropriate training is provided.
” 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 West London NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit and monitor non-controlled potent medication
Wider context from the report “(1) The evidence was that a variety of drugs and medications are dispensed from the hospital’s in-house pharmacy for use of individual patients on the individual wards. Only controlled drugs are audited and their whereabouts monitored. Among others, Opiate drugs are classed as non-controlled and therefore not audited. There is a real risk that potent medication could go unaccounted for and could end up in the possession of patients.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations