PFD report

Miles Benedict Abel · Prevention of Future Deaths report

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Issued 29 Jul 2016•Wiltshire and Swindon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of an audit trail for faxed referrals to the Community Mental Health Team
    Part of recurring concern: Unreliable mental health referral pathwaysPart of recurring concern: Unreliable tracking and completeness checking of faxed referrals and information
  2. Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
    Part of recurring concern: Unreliable mental health referral pathwaysPart of recurring concern: Unreliable tracking and completeness checking of faxed referrals and information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.

    Stated by The Endless Street Doctors’ SurgeryStated completedThe respondent said that this action was complete when they made their response on 29 July 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of an audit trail for faxed referrals to the Community Mental Health Team

Wider context from the report

“(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways; Unreliable tracking and completeness checking of faxed referrals and information.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals

Wider context from the report

“(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways; Unreliable tracking and completeness checking of faxed referrals and information.

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

Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.

Verbatim wording from the response

“Following the Critical Reporting Incident that followed the recent death of a patient, we have reviewed the system above and have instituted the new system – (Standard Operating Procedure - SOP enclosed):”

Source location

2016-0277-Response-by-The-Endless-Street-Doctors-Surgery
Page 1 · response
Published 29 July 2016

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.

Verbatim wording from the response

“Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.”

Source location

2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016

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

Responsibility for addressing the referral process rests locally with the surgery rather than centrally.

Verbatim wording from the response

“Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.”

Source location

2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Create an NHS paper-free point of care to help staff use digital technology.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2016.
  2. 2

    Use technology to reduce general-practice administrative work and provide patients with online services.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2016.
  3. 3

    Improve clinical decision-making by enabling patient-information flow across health and care settings.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 July 2016.

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

Create an NHS paper-free point of care to help staff use digital technology.

Verbatim wording from the response

“Although this is an issue to be addressed locally, the Government is taking forward the digitisation of the NHS. A plan of work covers a portfolio of 33 programmes to deliver the technology, digital and data enablers needed to underpin transformation in the health and social care system. The combined budget for the portfolio is circa £4.2bn. Several programmes will transform how the NHS operates and make better use of technology - for example:”

Source location

2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016

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

Use technology to reduce general-practice administrative work and provide patients with online services.

Verbatim wording from the response

“Although this is an issue to be addressed locally, the Government is taking forward the digitisation of the NHS. A plan of work covers a portfolio of 33 programmes to deliver the technology, digital and data enablers needed to underpin transformation in the health and social care system. The combined budget for the portfolio is circa £4.2bn. Several programmes will transform how the NHS operates and make better use of technology - for example:”

Source location

2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016

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

Improve clinical decision-making by enabling patient-information flow across health and care settings.

Verbatim wording from the response

“Although this is an issue to be addressed locally, the Government is taking forward the digitisation of the NHS. A plan of work covers a portfolio of 33 programmes to deliver the technology, digital and data enablers needed to underpin transformation in the health and social care system. The combined budget for the portfolio is circa £4.2bn. Several programmes will transform how the NHS operates and make better use of technology - for example:”

Source location

2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026