PFD report

Kirsty Lisa Pritchard · Prevention of Future Deaths report

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Issued 17 Oct 2014•Black Country

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised4

  1. Failure to report post-discharge patient contact to the responsible consultant in a timely manner
    Part of recurring concern: Failure to communicate clinically important information reliably between care services
  2. Lack of effective systems to action worsening symptoms and associated self-harm or suicide risk after discharge
  3. Deficiencies in systems for promptly contacting and locating patients at immediate risk of self harm
    Part of recurring concern: Failure to reliably locate people at immediate risk of suicide or self-harm
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.3

  1. Action

    Generate a start-of-shift list of patients referred to A&E and follow up attendance, taking further action where required.

    Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2014.
  2. Action

    Develop and apply a protocol requiring timely cold calls and police safe-and-well checks when immediate-risk service users cannot be contacted or located.

    Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2014.
  3. Action

    Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.

    Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2014.

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 report post-discharge patient contact to the responsible consultant in a timely manner

Wider context from the report

“(1)The Root cause analysis report by the Black Country Partnership NHS Trust confirmed that there were issues in relation to the communication of information. Specifically, the evidence presented at the inquest confirmed that CHTT contact with Ms Pritchard following discharge were not reported back to the inpatient Consultant in charge for review and assessment of risk of self harm in a timely fashion. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services.

Open source report

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 effective systems to action worsening symptoms and associated self-harm or suicide risk after discharge

Wider context from the report

“(2) I am concerned that the ability to undertake effective management of patient risks of self harm and suicide ideation upon discharge may be compromised if the Consultant in charge or equivalent is not made aware of worsening symptoms and that effective systems are not in place to action this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Deficiencies in systems for promptly contacting and locating patients at immediate risk of self harm

Wider context from the report

“(3) In addition, I am concerned that there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm and it took over 5 hours to find her despite the fact that the Police managed to locate her very quickly when they were subsequently contacted. ”

Is this part of a recurring concern?

Yes — Failure to reliably locate people at immediate risk of suicide or 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure that the responsible consultant is made aware of worsening symptoms after discharge

Wider context from the report

“(2) I am concerned that the ability to undertake effective management of patient risks of self harm and suicide ideation upon discharge may be compromised if the Consultant in charge or equivalent is not made aware of worsening symptoms and that effective systems are not in place to action this. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians; Failure to reliably notify responsible consultants about admissions and significant clinical changes.

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

Generate a start-of-shift list of patients referred to A&E and follow up attendance, taking further action where required.

Verbatim wording from the response

“Ms Pritchard was advised to attend A&E on 16 January 2013 having contacted CHITT, however there is no evidence that she presented herself at A&E on that occasion. Action has now been taken to ensure that at the start of each shift the CHITT team leader generates a list of all patients referred to A&E so that these can be followed up to ascertain if the patients did attend. This ensures that further action is taken if required. (the protocol for cold calls will be followed if non-attendance is established – see further explanation below).”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 2 · response
Published 17 October 2014

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

Develop and apply a protocol requiring timely cold calls and police safe-and-well checks when immediate-risk service users cannot be contacted or located.

Verbatim wording from the response

“In response to the concerns raised regarding the timescale for this response, a protocol has now been developed to address these issues. Where a service user is assessed to be in immediate risk of harm or death, and if telephone contact cannot be established with the service user within 30 minutes the CHITT are to carry out a cold call of the service user’s home address/ last known location within 1 hour. If CHITT are unable to gain access or locate the service user they are to contact the police to conduct a ‘safe and well’ check.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 3 · response
Published 17 October 2014

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

Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.

Verbatim wording from the response

“• The communication with consultants to raise any concerns has been reinforced by recirculating the medical escalation flow chart (Appendix 1) to all CHITT and inpatient staff both clinical and non-clinical so that it is clear which individual any concerns about risk should be raised with.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 2 · response
Published 17 October 2014

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.6

  1. 1

    Review CHITT processes and wider mental health services to improve communication, quality, access and continuity.

    Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2014.
  2. 2

    Strengthen CHITT involvement in inpatient discharge planning by ensuring attendance at all ward discharge planning meetings.

    Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2014.
  3. 3

    Implement agreed changes to the current CHITT and mental health service system following the strategy review.

    Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2014.
  4. 4

    Roll out Solution Focussed Therapy training to staff within the Acute Pathway.

    Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2014.
  5. 5

    Roll out STORM risk-management training to staff, including crisis services, adult mental health practitioners, new starters and staff requiring periodic updates.

    Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2014.
  6. 6

    Establish an in-house team of fifteen trainers to deliver Solution Focussed Therapy training tailored to local needs.

    Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    For people not under CHITT or inpatient care, directing them to A&E remains appropriate because crisis support, triage and twenty-four-hour access are available.

    Stated by Black Country Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review CHITT processes and wider mental health services to improve communication, quality, access and continuity.

Verbatim wording from the response

“The Trust processes, including the function and service provided by CHITT, are currently under review as part of a wider mental health strategy review. This is taking place in order to modernise services, improve quality of care and access to services. This review will also ensure a seamless service across both the adult and older adult population. The plan is to implement agreed changes to the current system by April 2015.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 1 · response
Published 17 October 2014

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 CHITT involvement in inpatient discharge planning by ensuring attendance at all ward discharge planning meetings.

Verbatim wording from the response

“Since the death of Ms Pritchard several actions have been taken to ensure that a more robust process is put in place pending the outcome of the trust-wide mental health strategy review. These are as follows:”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 2 · response
Published 17 October 2014

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 agreed changes to the current CHITT and mental health service system following the strategy review.

Verbatim wording from the response

“The Trust processes, including the function and service provided by CHITT, are currently under review as part of a wider mental health strategy review. This is taking place in order to modernise services, improve quality of care and access to services. This review will also ensure a seamless service across both the adult and older adult population. The plan is to implement agreed changes to the current system by April 2015.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 1 · response
Published 17 October 2014

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

Roll out Solution Focussed Therapy training to staff within the Acute Pathway.

Verbatim wording from the response

“• Solution Focussed Therapy (SFT) is also being rolled out to staff within the Acute Pathway. Staff have been trained in-house to deliver this training to ensure that it meets local needs. SFT is a skill based therapy that supports an individual’s coping skill development by enhancing their existing strengths. There is a team of fifteen trainers now in place with a roll out programme starting in 2015.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 3 · response
Published 17 October 2014

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

Roll out STORM risk-management training to staff, including crisis services, adult mental health practitioners, new starters and staff requiring periodic updates.

Verbatim wording from the response

“• All staff should be equipped to deal with risk assessment and management as part of the multi-disciplinary approach. The mental health division has identified an additional need for further staff training in responding to and recognising risks to and by service users in relation self-harm and suicide. STORM (Skills Based Training on Risk Management) training is prioritised to CHITT staff and other front line crisis services. There is a rolling plan over the next 36 months which commenced in November 2014 to capture all staff as well as new starters.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 2 · response
Published 17 October 2014

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

Establish an in-house team of fifteen trainers to deliver Solution Focussed Therapy training tailored to local needs.

Verbatim wording from the response

“• Solution Focussed Therapy (SFT) is also being rolled out to staff within the Acute Pathway. Staff have been trained in-house to deliver this training to ensure that it meets local needs. SFT is a skill based therapy that supports an individual’s coping skill development by enhancing their existing strengths. There is a team of fifteen trainers now in place with a roll out programme starting in 2015.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 3 · response
Published 17 October 2014

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

For people not under CHITT or inpatient care, directing them to A&E remains appropriate because crisis support, triage and twenty-four-hour access are available.

Verbatim wording from the response

“• The advice given to individuals not currently under the care of CHITT or inpatient services that require immediate advice or support remains to attend A&E in the first instance.”

Source location

2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Page 2 · response
Published 17 October 2014

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