PFD report

Evie Jane DAVIES · Prevention of Future Deaths report

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Issued 2 May 2024•Cheshire

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.

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Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 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 raised3

  1. Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable circulation of safety-critical mental health information
  2. Failure to notify the mental health team when a person has contacted the café71 service
    Part of recurring concern: Unreliable coordination of mental health crisis responses
  3. Delays in GP review of correspondence relevant to mental health team action
    Part of recurring concern: Unreliable circulation of safety-critical mental health 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.3

  1. Action

    Remind crisis line staff to include contact information in referrals and complete warm call transfers where possible.

    Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
  2. Action

    Audit referrals sent to Café 71 every six months and report findings through Acute Care and First Response governance meetings.

    Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
  3. Action

    Work with CWP and GP colleagues to improve the timeliness and content of correspondence about Crisis Line contacts.

    Stated by NHS Cheshire and Merseyside Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Existing procedures require Café 71 to contact relevant mental-health teams, attend professionals’ meetings and notify the Trust after three failed contact attempts.

    Stated by Cheshire and Wirral Partnership NHS Foundation TrustExisting 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 access by café71 staff to mental health team information about patients’ backgrounds and risk factors

Wider context from the report

“The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable circulation of safety-critical mental health information.

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 notify the mental health team when a person has contacted the café71 service

Wider context from the report

“The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner. ”

Is this part of a recurring concern?

Yes — Unreliable coordination of mental health crisis responses.

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

Delays in GP review of correspondence relevant to mental health team action

Wider context from the report

“The evidence I heard was that the café71 service is run as a crisis line for those who are in ’lesser crisis’ than those who would call mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team are operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between these organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner. ”

Is this part of a recurring concern?

Yes — Unreliable circulation of safety-critical mental health 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

Remind crisis line staff to include contact information in referrals and complete warm call transfers where possible.

Verbatim wording from the response

“At 20:27 on 1 December 2021 Café 71 staff emailed the crisis line as the referral did not contain a telephone number for Miss Davies. A telephone number was sent from the crisis line via email to Café 71 at 08:35 on 2 December 2021. A reminder has been issued to all”

Source location

Response from Cheshire and Wirral Partnership
Page 3 · response
Published 14 May 2024

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

Audit referrals sent to Café 71 every six months and report findings through Acute Care and First Response governance meetings.

Verbatim wording from the response

“The following learning has been undertaken by both the Trust and Café 71 to streamline how key information regarding individuals involved with mental health services can be shared with Café 71”

Source location

Response from Cheshire and Wirral Partnership
Page 5 · response
Published 14 May 2024

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

Work with CWP and GP colleagues to improve the timeliness and content of correspondence about Crisis Line contacts.

Verbatim wording from the response

“GP’s, along with other professionals can contact the Crisis Line directly and request mental health crisis support for individuals they are concerned about. CWP have a system in place to inform the GP when an individual has contacted Crisis Line and in line with the concern you raised we will work with CWP and GP colleagues to improve the timeliness and content of that correspondence.”

Source location

Response from Cheshire and Merseyside
Page 1 · response
Published 14 May 2024

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

Existing procedures require Café 71 to contact relevant mental-health teams, attend professionals’ meetings and notify the Trust after three failed contact attempts.

Verbatim wording from the response

“If an individual is known to Community Mental Health Team, Café 71 will link in with the individual’s key workers, this is via email or phone contact. This is set out in the current Community Mental Health Team Standard Operating Procedure. Café 71 staff are also invited to attend professionals’ meetings to provide feedback on the progress of the individual attending Café 71, including the level of engagement with the cafe, when an individual had completed their programme and offer recommendations for future support if appropriate.”

Source location

Response from Cheshire and Wirral Partnership
Page 5 · response
Published 14 May 2024

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

Café 71 does not operate in isolation; staff can obtain relevant mental-health information from Trust crisis-line staff with the individual’s consent.

Verbatim wording from the response

“Café 71 do not have access to the Trust’s electronic Patient record system (SystmOne). However, the staff from Café 71 will contact crisis line staff to discuss any risk concerns, the teams work closely to ensure that the relevant information relating to a patient’s mental health is available to Café 71 staff. Café 71 staff can phone the crisis line to request further information, but more often the member of staff requiring the information will physically call into the office. Contacts between services are undertaken with patient knowledge and consent. The Trust would seek consent from the individual to refer them to Café 71.”

Source location

Response from Cheshire and Wirral Partnership
Page 4 · response
Published 14 May 2024

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

The NHS Crisis Line, which received the call, was responsible for notifying the mental health team.

Verbatim wording from the response

“Also in point 5, there is a sentence regarding a lack of notification to the mental health team about EJD being in contact, but again, this would be the Crisis Line who would notify the mental health team as it was them who received the phone call.”

Source location

Response from Spider Project
Page 2 · response
Published 14 May 2024

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

Cafe 71 disputes that EJD contacted it, that it was a crisis line, or that referral information indicated immediate risk.

Verbatim wording from the response

“In point 4 of the report it says that EJD called the Crisis Line and was directed to Cafe 71. We want to make it clear that EJD did not ever call Cafe 71, the only call that we are aware of was to the NHS Crisis Line.”

Source location

Response from Spider Project
Page 2 · response
Published 14 May 2024

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.1

  1. 1

    Enhance Café 71 referral forms to capture voicemail consent and support already provided by the referrer.

    Stated by Spider Project Café71Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Café 71 is not operated as a crisis line or alternative to the Trust’s crisis line; it provides additional, non-clinical support.

    Stated by Cheshire and Wirral Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Direct GP contact is available when clinically appropriate, while routine post-contact notification is considered sufficient in many cases.

    Stated by Cheshire and Wirral Partnership 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

Enhance Café 71 referral forms to capture voicemail consent and support already provided by the referrer.

Verbatim wording from the response

“Action taken: - Referral forms for Café 71 are now more detailed, asking for consent to be obtained by the referrer whether staff can leave a voicemail from the point of referral. We also ask the referrer about what referrals/support have been put in place following their contact with the individual they are referring.”

Source location

Response from Spider Project Cafe 71
Page 2 · response
Published 14 May 2024

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

Café 71 is not operated as a crisis line or alternative to the Trust’s crisis line; it provides additional, non-clinical support.

Verbatim wording from the response

“Café 71 is a community service which operates both open access direct for the population and through referrals from partners such as Primary care (GPs) and CWP. The service is commissioned by CWP to offer advice, guidance and crisis support to anyone aged 18 and over who are experiencing a self-defined crisis. Café 71 staff support individuals by helping them to de-escalate and resolve the crisis situations, the staff also work with the individual to recognise any underlying factors and supports onward referral and signposting to relevant services. By way of clarification, Café 71 operates between 10 am and 10 pm daily, it is not “run as a crisis line” as stated in the Regulation 28 report, to which this letter responds.”

Source location

Response from Cheshire and Wirral Partnership
Page 2 · response
Published 14 May 2024

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

Direct GP contact is available when clinically appropriate, while routine post-contact notification is considered sufficient in many cases.

Verbatim wording from the response

“GPs can be contacted directly if concerns are raised during the crisis line triage assessment and from other services within the Trust, if it is appropriate to do so. Often, as the crisis line is a more intensive, immediate resource than an individual contacting their GP; it is sufficient to update the GP for their information following contacts.”

Source location

Response from Cheshire and Wirral Partnership
Page 6 · response
Published 14 May 2024

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