PFD report

Duncan HOLLOWAY · Prevention of Future Deaths report

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Issued 20 Feb 2025•Inner North London

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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: 5
Recipients: 2
Responses found: 2
Stated actions: 8

Recipients and published responses

British Association For Counselling And PsychotherapyResponse found North London NHS Foundation TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 2 August 2024, I commenced an investigation into the death of Duncan Holloway, aged 36 years. The investigation concluded at the end of the inquest on 16 January 2025. I do apologise for the late provision of this report.

I made a determination at inquest of death by suicide.

Coroner’s concerns

For BCAP:

1. Mr Holloway’s BCAP accredited psychotherapist did not make any notes of her consultations with him, because he had asked her not to. She gave evidence that she is not bound by law or ethics to keep any notes.

Is it appropriate that there is no minimum standard of note keeping following psychotherapy consultations?

2. The psychotherapist said that she had never before had a client who was suicidal. She said that this is not taught at university, though she had completed a post graduate course in working with suicidal ideation.

Can it be right that suicidality is completely omitted from BCAP accredited psychotherapy training?

3. When Mr Holloway’s friend contacted the psychotherapist to say that he was missing, knowing that he had neither attended nor cancelled their last consultation the psychotherapist was very concerned for his safety. She instructed the friend to go round to his home, but it did not occur to her to call the police.

The friend did this, but can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning?

4. The psychotherapist explained in court that she was angry that Mr Holloway’s friend disclosed to her that Mr Holloway had died, asking the friend: “Do you have any idea how this impacts me and my ability to do my job going forward?” The psychotherapist said that she (the psychotherapist) was in distress and shock.

In hindsight, the psychotherapist said that she wished she had referred Mr Holloway to a psychotherapist with more experience in suicidality, she said at inquest because she did not want to be in this situation again with this responsibility.

Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with suicidality does not practise with clients who may experience this?

For BCAP and North West London NHS Trust:

5. Mr Holloway was seen and fully assessed by North West London clinicians when he was taken to hospital by police following an episode of self harm on 30 June 2024. Police attendance had been prompted by Mr Holloway’s brother, calling from abroad.

Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined up between the different agencies.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it
Failure to provide joined-up care between different agencies
Part of recurring concern: Failure to provide continuity of patient care
Omission of suicidality from BCAP-accredited psychotherapy training

Responses linked to these concerns

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

Actions described in response 5

Action
Prevent registration of individuals who have not passed an accredited course or equivalent certificate of proficiency.
Stated by British Association For Counselling And PsychotherapyStated completed
Action
Require accredited-course students to learn when confidentiality may be breached, including referral to emergency services where necessary.
Stated by British Association For Counselling And PsychotherapyStated completed
Action
Require members to keep accurate, necessary and data-protection-compliant records.
Stated by British Association For Counselling And PsychotherapyStated completed

Respondent positions 6

Position
Existing processes require enquiries about support networks and promptly sending mental health assessment summaries to service users’ GPs.
Stated by North London NHS Foundation TrustExisting arrangements considered sufficient

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 3

1
Share learning from the incident through the Trust’s governance forums to support improvement.
Stated by North London NHS Foundation TrustStated planned
2
Continue reflecting on the incident through the Trust’s governance and learning processes.
Stated by North London NHS Foundation TrustStated in progress
3
Require members to agree and clearly communicate service terms, confidentiality arrangements and records of agreements with clients.
Stated by British Association For Counselling And PsychotherapyStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised5

Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it

Failure to provide joined-up care between different agencies

Omission of suicidality from BCAP-accredited psychotherapy training

Lack of a minimum standard for psychotherapy consultation note keeping

Failure to teach police contact in psychotherapy planning for missing or suicidal clients

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

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

Actions described in response 5

Respondent positions 6

Recipient-stated actions 3