PFD report

Ursula Niamh MacEochaigh Keogh · Prevention of Future Deaths report

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Issued 21 Nov 2018•West Yorkshire (Western)

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
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
7

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. Failure to ensure CAMHS referral pathways remain operable where school psychology services are unavailable
    Part of recurring concern: Unreliable mental health referral pathways
  2. Failure to provide consistent referral advice between health and education professionals
    Part of recurring concern: Failure to integrate mental health and education pastoral services
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

    Review the CAMHS referral pathway for GPs and schools.

    Stated by NHS West Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
  2. Action

    Provide 24/7 crisis care access for children, young people and their families through NHS111 by 2023/24.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.
  3. Action

    Establish Mental Health Support Teams in and near schools and colleges through 25 trailblazer sites to provide earlier support for children and young people.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.

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

  1. Position

    The existing CAMHS referral pathway was considered accurate and sufficient, although external training and education gaps required new actions.

    Stated by NHS West Yorkshire Integrated Care BoardExisting 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

Failure to ensure CAMHS referral pathways remain operable where school psychology services are unavailable

Wider context from the report

“During the inquest I heard that Ursula’s mother contacted Ursula’s GP at Spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP, during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school, so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway, notwithstanding that at this time the school did not have the services of a Psychology team to make the referral. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 provide consistent referral advice between health and education professionals

Wider context from the report

“During the inquest I heard that Ursula’s mother contacted Ursula’s GP at Spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP, during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school, so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway, notwithstanding that at this time the school did not have the services of a Psychology team to make the referral. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health and education pastoral services.

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

Review the CAMHS referral pathway for GPs and schools.

Verbatim wording from the response

“1. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS.”

Source location

2018-0370-Response-by-Calderdale-CCG
Page 1 · response
Published 10 May 2019

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

Provide 24/7 crisis care access for children, young people and their families through NHS111 by 2023/24.

Verbatim wording from the response

“You may also wish to note that the Government published the first cross-Government Suicide Prevention Workplan in January 2019 which set out an ambitious programme to reduce suicides, including in children and young people⁶. Furthermore, setting up 24/7 crisis care provision for children, young people and their families is a key priority for the Government in the NHS Long Term Plan⁷, published on 7 January 2019. All children and young people experiencing crisis will be able to access crisis care 24 hours a day, seven days a week by 2023/24 via NHS111.”

Source location

2018-0370-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 10 May 2019

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 Mental Health Support Teams in and near schools and colleges through 25 trailblazer sites to provide earlier support for children and young people.

Verbatim wording from the response

“On 20 December 2018, the Government announced the first wave of 25 trailblazer sites that will test the plans set out in the Green Paper. These new plans will significantly increase the availability of mental health support to children and young people, including creating new Mental Health Support Teams working in and near schools and colleges to support children and young people with mild to moderate mental health conditions. Mental Health Support Teams will provide brand new”

Source location

2018-0370-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 10 May 2019

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 existing CAMHS referral pathway was considered accurate and sufficient, although external training and education gaps required new actions.

Verbatim wording from the response

“1. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS.”

Source location

2018-0370-Response-by-Calderdale-CCG
Page 1 · response
Published 10 May 2019

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

Local NHS services and local authorities are responsible for responding to the concerns and learning from deaths to improve service safety.

Verbatim wording from the response

“Your report raises three matters of concern and is directed to NHS Calderdale Clinical Commissioning Group (CCG) and Calderdale Council, as well as the Department of Health and Social Care. I am aware that the Calderdale CCG has responded to your concerns from a local perspective, advising you of a series of actions that are being undertaken in light of the report. We expect the local NHS to take action to respond to concerns and learn from deaths to ensure the safety of healthcare services and I am encouraged that the local NHS is looking into these matters carefully.”

Source location

2018-0370-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 10 May 2019

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.4

  1. 1

    Assign the Open Mind Partnership Steering Group ownership of the action plan and monitor its delivery through monthly meetings and quality reporting.

    Stated by NHS West Yorkshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.
  2. 2

    Publish the cross-Government Suicide Prevention Workplan setting out measures to reduce suicides, including among children and young people.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
  3. 3

    Work with DCMS and online providers to address harmful suicide and self-harm content and tackle online harms.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 May 2019.
  4. 4

    Set out legislative and non-legislative measures to tackle online harms through the forthcoming joint Online Harms White Paper.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.

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

  1. 1

    Calderdale Council was assigned responsibility for providing the full response on fast-tracking preventative measures at North Bridge.

    Stated by NHS West Yorkshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Assign the Open Mind Partnership Steering Group ownership of the action plan and monitor its delivery through monthly meetings and quality reporting.

Verbatim wording from the response

“The multi-agency Open Mind Partnership (CAMHS) Steering Group will take ownership of the attached action plan. The Steering Group will monitor delivery against this plan at its monthly meeting, reporting into the CCG’s Quality Committee.”

Source location

2018-0370-Response-by-Calderdale-CCG
Page 2 · response
Published 10 May 2019

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

Publish the cross-Government Suicide Prevention Workplan setting out measures to reduce suicides, including among children and young people.

Verbatim wording from the response

“You may also wish to note that the Government published the first cross-Government Suicide Prevention Workplan in January 2019 which set out an ambitious programme to reduce suicides, including in children and young people⁶. Furthermore, setting up 24/7 crisis care provision for children, young people and their families is a key priority for the Government in the NHS Long Term Plan⁷, published on 7 January 2019. All children and young people experiencing crisis will be able to access crisis care 24 hours a day, seven days a week by 2023/24 via NHS111.”

Source location

2018-0370-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 10 May 2019

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 DCMS and online providers to address harmful suicide and self-harm content and tackle online harms.

Verbatim wording from the response

“The Department is very concerned about the impact of this sort of content and is working with the Department for Digital, Culture, Media and Sport (DCMS) and the online sector to address this. Our ambition is to make the UK the safest place to be online and we are working with internet and social media providers to tackle online harms such as these.”

Source location

2018-0370-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 10 May 2019

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

Set out legislative and non-legislative measures to tackle online harms through the forthcoming joint Online Harms White Paper.

Verbatim wording from the response

“You may be aware that the Secretary of State for Health and Social Care, Matt Hancock, wrote to social media providers in January to express his concern about suicide and self-harm content on their platforms. I also met social media providers in February, alongside the Secretary of State, and they have committed to step-up their efforts to protect their users from harmful suicidal and self-harm content online. We are also taking action through the forthcoming joint DCMS and Home Office Online”

Source location

2018-0370-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 10 May 2019

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

Calderdale Council was assigned responsibility for providing the full response on fast-tracking preventative measures at North Bridge.

Verbatim wording from the response

“3. Consider the appropriateness of fast tracking the implementation of preventative measures currently under consideration at North Bridge Halifax”

Source location

2018-0370-Response-by-Calderdale-CCG
Page 2 · response
Published 10 May 2019

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