PFD report

Harry David HALL · Prevention of Future Deaths report

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Issued 1 May 2024•Northumberland

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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

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Concerns raised1

  1. Failure to record the reason for a missed appointment and whether an assessment was undertaken
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable recording of safety-critical mental health information
Responses linked to these concerns

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

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

  1. Position

    The Trust disputes that a cancelled appointment lacked rationale and says assessment remained within the applicable 18-week timeframe.

    Stated by Cumbria, Northumberland, Tyne and Wear 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 record the reason for a missed appointment and whether an assessment was undertaken

Wider context from the report

“The deceased was seen by his General Practitioner on 27 March 2023 when he described ongoing suicidal ideation. His General Practitioner referred him to the 24-hour crisis team at 17.56 hours on 27 March 2023. The Initial Response Team ("IRT") provides 24 hour access to urgent mental health care and treatment. The IRT called the deceased at 22.37hrs on 27 March 2023 and I am told during which no immediate risks of self-harm were identified and although frequent thoughts of suicide were being experienced they were felt to be chronic in nature. The clinical decision was to not to refer on the Crisis Team and instead refer to the West Northumberland Community Treatment Team. There were two letters the first dated 31 March 2023 offering an appointment on 17 May 2023 and the second dated 4 April offering an appointment on 26 June 2023. I heard there was a ten week delay in appointments although that delay has since been rectified. The appointment on 17 May 2023 did not go ahead. No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording of safety-critical mental health information.

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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 Trust disputes that a cancelled appointment lacked rationale and says assessment remained within the applicable 18-week timeframe.

Verbatim wording from the response

“There was therefore no cancelled appointment and therefore no omission of rationale for the perceived cancellation. Furthermore, as was explained in the hearing, Mr Hall would have been seen within the 18 week timeframe that was the appropriate benchmark at the time.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear
Page 2 · response
Published 9 May 2024

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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