PFD report

Jamie Peter Norman PILKINGTON · Prevention of Future Deaths report

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Issued 22 Feb 2024•Staffordshire and Stoke-on-Trent

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
8

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 communicate onward care plans and timescales
  2. Inadequate exploration of matters affecting suicide risk
    Part of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable assessment of suicide and self-harm risk
  3. Failure to provide suicide-risk coping and service-contact information
    Part of recurring concern: Failure to provide accessible suicide-prevention service information to people at risk
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.4

  1. Action

    Include families and carers in collaborative safety planning.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
  2. Action

    Explore adding the Safetool safety-planning function to the electronic patient record.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
  3. Action

    Roll out collaborative safety planning, replacing traditional suicide risk-assessment approaches.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Failure to complete the FACE risk assessment does not indicate inadequate suicide-risk management because such tools cannot accurately predict suicide or self-harm.

    Stated by Midlands Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 communicate onward care plans and timescales

Wider context from the report

“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023 1. Suicidal/self-harm thoughts not explored in detail. 2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. 3. There was no exploration regarding efficacy/concordance with medication. 4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. 5. There was no discussion regarding his support network, next of kin etc. 6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed. ”

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

Inadequate exploration of matters affecting suicide risk

Wider context from the report

“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023 1. Suicidal/self-harm thoughts not explored in detail. 2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. 3. There was no exploration regarding efficacy/concordance with medication. 4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. 5. There was no discussion regarding his support network, next of kin etc. 6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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 suicide-risk coping and service-contact information

Wider context from the report

“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023 1. Suicidal/self-harm thoughts not explored in detail. 2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. 3. There was no exploration regarding efficacy/concordance with medication. 4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. 5. There was no discussion regarding his support network, next of kin etc. 6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed. ”

Is this part of a recurring concern?

Yes — Failure to provide accessible suicide-prevention service information to people at risk.

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 complete suicide risk assessments

Wider context from the report

“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023 1. Suicidal/self-harm thoughts not explored in detail. 2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. 3. There was no exploration regarding efficacy/concordance with medication. 4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. 5. There was no discussion regarding his support network, next of kin etc. 6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Include families and carers in collaborative safety planning.

Verbatim wording from the response

“• Family and carer engagement; ensuring that families and carers are included in safety planning,”

Source location

Response from Midlands Partnership NHS
Page 3 · response
Published 26 February 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

Explore adding the Safetool safety-planning function to the electronic patient record.

Verbatim wording from the response

“We are exploring the addition of the Safetool (safety planning) onto our electronic patient record system to support the electronic completion of this.”

Source location

Response from Midlands Partnership NHS
Page 2 · response
Published 26 February 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

Roll out collaborative safety planning, replacing traditional suicide risk-assessment approaches.

Verbatim wording from the response

“MPFT has developed a three-year suicide prevention plan to address the changes in guidance and practice required to move from the traditional risk assessment and management approaches used in suicide to those of collaborative safety planning led by service users. This plan has five key components:”

Source location

Response from Midlands Partnership NHS
Page 3 · response
Published 26 February 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

Train staff in suicide awareness, risk formulation and collaborative safety planning across the organisation.

Verbatim wording from the response

“MPFT has explored the guidance and what this means for clinicians working with those who may be at risk of suicide. It is recognised that the existing FACE risk assessment is no longer indicated for use in suicide as it is not possible to predict suicide due to the dynamic nature of this. There is building evidence of the effectiveness of safety planning in suicide mitigation, which requires the training and roll out of safety planning skills and tools across the whole organisation. By December 2023 we had trained 1281 staff across the trust in suicide awareness training (e-learning), the safety planning training is face to face and is resource intensive to deliver due to ensuring fidelity against the model therefore numbers for this are lower.”

Source location

Response from Midlands Partnership NHS
Page 2 · response
Published 26 February 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

Failure to complete the FACE risk assessment does not indicate inadequate suicide-risk management because such tools cannot accurately predict suicide or self-harm.

Verbatim wording from the response

“While the FACE risk assessment was not completed on this occasion, the purpose of the tool is to guide clinical discussions with service users in order to identify and explore areas of risk. Completion of the FACE risk assessment, and indeed any risk indicator tool is no longer seen as an effective predictor of suicide. This is highlighted in the revised NICE guidance NG225 Self-Harm: assessment, management and preventing recurrence (Sept. 2022), which guides services not to use assessment tools and scales to predict future suicide or repetition of self-harm. Instead, clinicians are to focus the assessment on the person’s needs and how to support their immediate and long-term psychological and physical safety.”

Source location

Response from Midlands Partnership NHS
Page 1 · response
Published 26 February 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.4

  1. 1

    Monitor suicide risk through real-time surveillance, patient-safety incident reviews and learning-from-deaths processes.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
  2. 2

    Discuss agreed learning points within the team and disseminate them by follow-up email.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  3. 3

    Deliver the delayed informal training session to staff on 9 April 2024.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
  4. 4

    Develop a three-year suicide-prevention plan addressing changes in guidance and clinical practice.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.

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

Monitor suicide risk through real-time surveillance, patient-safety incident reviews and learning-from-deaths processes.

Verbatim wording from the response

“• Monitoring; engagement in real time suicide surveillance, patient safety incident review and learning from deaths process.”

Source location

Response from Midlands Partnership NHS
Page 3 · response
Published 26 February 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

Discuss agreed learning points within the team and disseminate them by follow-up email.

Verbatim wording from the response

“Upon completion of the initial report and agreeing the learning points, these were discussed within the team on 25th October 2023. A follow up email was sent to capture these points, allowing staff the opportunity to discuss further if required.”

Source location

Response from Midlands Partnership NHS
Page 3 · response
Published 26 February 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

Deliver the delayed informal training session to staff on 9 April 2024.

Verbatim wording from the response

“The informal training session was scheduled for 27th February 2024, however due to unseen circumstances this has been delayed until the 9th April 2024.”

Source location

Response from Midlands Partnership NHS
Page 3 · response
Published 26 February 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

Develop a three-year suicide-prevention plan addressing changes in guidance and clinical practice.

Verbatim wording from the response

“MPFT has developed a three-year suicide prevention plan to address the changes in guidance and practice required to move from the traditional risk assessment and management approaches used in suicide to those of collaborative safety planning led by service users. This plan has five key components:”

Source location

Response from Midlands Partnership NHS
Page 3 · response
Published 26 February 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