PFD report

Grant David Burns · Prevention of Future Deaths report

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Issued 23 Feb 2017•Southampton and New Forest

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
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 raised3

  1. Lack of communication between partner agencies
  2. Lack of co-operative working between early intervention in psychosis and substance misuse services
    Part of recurring concern: Unreliable integration of substance misuse services into patient care
  3. Failure to obtain key worker input for root cause analysis
    Part of recurring concern: Unreliable root cause analysis processes
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.5

  1. Action

    Create a Joint Working Practice document setting communication, joint-working and escalation standards for Substance Misuse Services and Adult Mental Health.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
  2. Action

    Implement a referral process that identifies mental health involvement, initiates cross-service contact and joint working, assigns responsibility, and escalates unanswered contacts.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
  3. Action

    Maintain a shared spreadsheet of clients receiving Adult Mental Health and Substance Misuse Services, with updates through joint and standing meeting agendas.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.

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 communication between partner agencies

Wider context from the report

“There was a lack of communication between partner agencies ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 co-operative working between early intervention in psychosis and substance misuse services

Wider context from the report

“The death was the subject of Root Cause Analysis report by Southern Health NHS Foundation Trust who provided the Early Intervention in Psychosis Service (EIPS) for the deceased, which found there was a lack of co-operative working between the EIPS and the Substance Misuse Service based at New Road Southampton provided by Solent NHS Trust ”

Is this part of a recurring concern?

Yes — Unreliable integration of substance misuse services into patient care.

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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 obtain key worker input for root cause analysis

Wider context from the report

“The Southern Health report highlighted that their report was incomplete because there was no input from the key worker at New Road despite best efforts ”

Is this part of a recurring concern?

Yes — Unreliable root cause analysis processes.

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

Create a Joint Working Practice document setting communication, joint-working and escalation standards for Substance Misuse Services and Adult Mental Health.

Verbatim wording from the response

“Finally the seventh action is with regard to the third issue of the lack of communication between partner agencies. The action is to create a bespoke Joint Working Practice document to outline the standards expected of staff in Substance Misuse Services and Adult Mental Health with regard to communication between organisations where patients are supported by both. These standards should cover, though are not limited to: Frequency of contact; Joint visits/meetings and escalation process. This action commenced on the 3rd of April and is due to end on the 18th of April 2017. The outcome of the action is to maintain consistent shared knowledge of patients’ risks and needs, and how these can be addressed. It is anticipated that there will then be a clear understanding by patients and carers regarding the involvement of different services, including their roles and functions.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 2 · response
Published 5 March 2017

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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 a referral process that identifies mental health involvement, initiates cross-service contact and joint working, assigns responsibility, and escalates unanswered contacts.

Verbatim wording from the response

“The second action concerns referrals which are screened in Substance Misuse Services. The Change Grow Live Manager with the Solent NHS Trust Clinical Manager will identify if there is any involvement from mental health services. If Adult Mental Health is involved, contact is to be made via telephone call/letter or email with the mental health treating team to make them aware that the Substance Misuse Services are also involved in the patient’s care. A meeting will then be arranged to start the joint working process. A named staff member will be identified to take responsibility for this action, which will usually be the Change Grow Live Care Co-Ordinator. Should there be no response from the mental health team following the substance misuse workers making contact, they will escalate this to their line manager to raise with the Area Manager – Southampton Mental Health Team Manager.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 1 · response
Published 5 March 2017

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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

Maintain a shared spreadsheet of clients receiving Adult Mental Health and Substance Misuse Services, with updates through joint and standing meeting agendas.

Verbatim wording from the response

“After a full assessment, it has been found that in this incident there was a lack of co-operative working between Southern Health mental health services (Early Intervention in Psychosis Team) and Substance Misuse Services. After some discussion, the action now required is to compile a spread-sheet of those clients identified as being worked with by Adult Mental Health and Substance Misuse Services. This spread-sheet needs to be updated at the Southampton Drug and Alcohol Recovery Service Management meeting with regular communication with Southern Health Foundation Trust. This action was put in place on the 27th of March 2017 and is due to end on the 1st of April 2017. The desired outcome of this action is to improve clients’ experience of services, working cohesively and consistently to support risks and the individuals’ recovery.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 1 · response
Published 5 March 2017

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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 Serious Incident Requiring Investigation policies to require investigators to engage all known stakeholders and services involved in a person’s care.

Verbatim wording from the response

“In relation to issue 2, namely the report being incomplete because there was no input from the key worker at New Road, a number of actions have been put in place. In this particular instance, the incomplete reports were due to lack of input from both Substance Misuse Services and Adult Mental Health in relation to Serious Incident Requiring Investigation reports. In order to avoid this from happening again an action has been put in place to review the current Serious Incident Requiring Investigation policies for both Southern Health Foundation Trust and Solent NHS Trust to ensure the explicit requirement of Serious Incident requiring investigation investigators to engage with all key stakeholders/services who were/are involved in a person’s care, and offer them input into the investigation process.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 2 · response
Published 5 March 2017

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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 Dual Diagnosis Policy across Southern Health Foundation Trust and Solent NHS Trust to include the joint-working process as staff best practice.

Verbatim wording from the response

“The third action is to review the Dual Diagnosis Policy within Southern Health Foundation Trust and Solent NHS Trust to ensure that the action above is included within it as best practice for staff to follow. This action commenced on the 3rd of April 2017 and is due to end on the 1st of May 2017.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 1 · response
Published 5 March 2017

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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.3

  1. 1

    Undertake an annual audit of compliance with standards set in the Dual Diagnosis Policy.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
  2. 2

    Undertake an annual audit of compliance with standards set in the Serious Incident Requiring Investigation policies.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
  3. 3

    Undertake an annual audit of compliance with standards set in the joint-working policies.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.

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

Undertake an annual audit of compliance with standards set in the Dual Diagnosis Policy.

Verbatim wording from the response

“The fourth action is to undertake an annual audit of compliance against the standards set within the policy. This is due to be put in place in September 2017 and will end in April 2018.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 2 · response
Published 5 March 2017

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

Undertake an annual audit of compliance with standards set in the Serious Incident Requiring Investigation policies.

Verbatim wording from the response

“Action 6 is to undertake an annual audit of compliance against the standards set within the policies. This action will be put in place in September 2017 and will end in April 2018.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 2 · response
Published 5 March 2017

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

Undertake an annual audit of compliance with standards set in the joint-working policies.

Verbatim wording from the response

“Finally the eighth action is to undertake an annual audit of compliance against the standards set within the policies. This action is due to be put in place in September 2017 and will end in April 2018.”

Source location

2017-0048-Response-by-Solent-NHS-Trust
Page 2 · response
Published 5 March 2017

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