Recipient

Wife of the deceased

First report 21 Aug 2013•Latest report 21 Aug 2013

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Wife of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

21 Aug2013
West Sussex
Concerns raised7
1. Scalable fences surrounding ward external common areas
2. Failure to document the rationale and risk factors underlying changes in observation levels
3. Failure to communicate risk-care-planning issues among all MDT members
1. Failure to align observation levels with changing suicidal risk
2. Failure to revisit and revise risk care plans
3. Delays in declaring an AWOL patient missing and informing the police
4. Insufficient scope and depth of risk care planning
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

Mr Walker · 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 Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Scalable fences surrounding ward external common areas
Wider context from the report
“(4) At the time of the incident the fences surrounding the external common areas of the ward were of a scalable height by any patient determined enough to do so. It is accepted that this has been subsequently addressed. ”
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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure to document the rationale and risk factors underlying changes in observation levels
Wider context from the report
“(2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts in the week before his death), without explanation, remains of concern. ”
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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate risk-care-planning issues among all MDT members
Wider context from the report
“(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”
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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure to align observation levels with changing suicidal risk
Wider context from the report
“(2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts in the week before his death), without explanation, remains of concern. ”
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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure to revisit and revise risk care plans
Wider context from the report
“(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”
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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Delays in declaring an AWOL patient missing and informing the police
Wider context from the report
“(3) Whilst it was accepted in evidence that the hospital's AWOL policy was robust and activated and implemented appropriately, concern was raised by the family with regard to the length of time taken before Mr Walker could be declared missing and the police informed. ”
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 Wife of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Insufficient scope and depth of risk care planning
Wider context from the report
“(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Scalable fences surrounding ward external common areas

Failure to document the rationale and risk factors underlying changes in observation levels

Failure to communicate risk-care-planning issues among all MDT members

Failure to align observation levels with changing suicidal risk

Failure to revisit and revise risk care plans

Delays in declaring an AWOL patient missing and informing the police

Insufficient scope and depth of risk care planning