18 Mar 2014 David Gary Chatburn · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 9 Failure to make case-specific referrals through the single point of entry process View source Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning View source Unnecessarily bureaucratic and deterrent processes for accessing mental health services View source Unavailability of direct referral to in-house community-based psychiatrists for new patients View source Failure to ensure medically qualified practitioner management of single point of entry triage View source Restrictions on cross-Clinical Commissioning Group referrals without special approval View source Failure of contemporaneous record keeping to support clinical recollections View source Failure to use recognised assessment tools in clinical evaluation View source Failure to assess medication appropriateness in light of patients’ mental health history 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
David Gary Chatburn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.
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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to make case-specific referrals through the single point of entry process
Wider context from the report “4. That the GP felt it was sufficient for him to simply discuss the deceased’s care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process . Such discussions were not necessarily case specific in any event but rather, general in nature .
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning
Wider context from the report “1. That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan . The GP considered that there was no need, as he felt clinically competent to manage the deceased’s care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest (‘GPwSPi’) and whilst confident in his ability to manage the deceased’s care, his area of special interest was in fact the management of addictions.
Irrespective, he felt that he was best placed to assess, diagnose and treat the deceased on the basis that had he referred Mr Chatburn to the single point of entry system, the person ‘triaging’ would not have been medically qualified and would not have known the deceased as well as he felt he did.
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Unnecessarily bureaucratic and deterrent processes for accessing mental health services
Wider context from the report “7. That the processes GPs are expected to use in order to access mental health services for their patients are unnecessarily bureaucratic and deterrent . GPs can no longer simply contact a Consultant Psychiatrist directly for advice. Everything must pass through the single point of entry.
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Unavailability of direct referral to in-house community-based psychiatrists for new patients
Wider context from the report “3. That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist , thus effectively defeating the object.
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medically qualified practitioner management of single point of entry triage
Wider context from the report “8. That the ‘triage’ process used by the single point of entry system is not always managed by a medically qualified practitioner – this being a vital stage in determining diversion/allocation .
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Restrictions on cross-Clinical Commissioning Group referrals without special approval
Wider context from the report “9. That GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same . In order to do so, a ‘special case’ must be argued . This potentially limits patient (and practitioner) accessibility and 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure of contemporaneous record keeping to support clinical recollections
Wider context from the report “5. That the GP’s recollection of events was not supported by contemporaneous record keeping , thus calling into question accuracy.
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to use recognised assessment tools in clinical evaluation
Wider context from the report “6. That the GP did not use a recognised assessment tool, as an adjunct or otherwise, in his clinical evaluation of the deceased . He felt that they were ineffective and of little, if any, value.
” 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 York House Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to assess medication appropriateness in light of patients’ mental health history
Wider context from the report “2. That the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient’s past mental health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations