PFD report

Duncan HOLLOWAY · Prevention of Future Deaths report

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Issued 20 Feb 2025•Inner North London

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
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

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 raised5

  1. Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it
  2. Failure to provide joined-up care between different agencies
    Part of recurring concern: Failure to provide continuity of patient care
  3. 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 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

    Prevent registration of individuals who have not passed an accredited course or equivalent certificate of proficiency.

    Stated by British Association For Counselling And PsychotherapyStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  2. 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 completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  3. Action

    Require members to keep accurate, necessary and data-protection-compliant records.

    Stated by British Association For Counselling And PsychotherapyStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.

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

  1. 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 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

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

Wider context from the report

“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? ”

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

Failure to provide joined-up care between different agencies

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of patient care.

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

Omission of suicidality from BCAP-accredited psychotherapy training

Wider context from the report

“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? ”

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

Lack of a minimum standard for psychotherapy consultation note keeping

Wider context from the report

“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? ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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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 teach police contact in psychotherapy planning for missing or suicidal clients

Wider context from the report

“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? ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

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

Prevent registration of individuals who have not passed an accredited course or equivalent certificate of proficiency.

Verbatim wording from the response

“4. 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?”

Source location

Response from BACP
Page 3 · response
Published 25 February 2025

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

Require accredited-course students to learn when confidentiality may be breached, including referral to emergency services where necessary.

Verbatim wording from the response

“According to the BACP Accreditation of Training Courses, all students enrolled in BACP-accredited courses must be trained in making informed decisions about breaching confidentiality when necessary. This includes understanding when it is appropriate to refer clients, particularly in situations requiring emergency intervention.”

Source location

Response from BACP
Page 3 · response
Published 25 February 2025

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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

Require members to keep accurate, necessary and data-protection-compliant records.

Verbatim wording from the response

“All BACP members must adhere to BACP’s Ethical Framework.”

Source location

Response from BACP
Page 1 · response
Published 25 February 2025

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

Require accredited courses to teach evidence-based risk assessment, safety planning, therapeutic contracting and referral to appropriate agencies.

Verbatim wording from the response

“BACP accredited courses, must meet all the course requirements set by BACP. These requirements ensure that all students on accredited courses must be trained in evidenced-based risk assessment strategies and must be taught to negotiate an appropriate therapeutic contract which may include referral.”

Source location

Response from BACP
Page 2 · response
Published 25 February 2025

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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

Provide members with evidence-based guidance resources on confidentiality and record keeping.

Verbatim wording from the response

“In addition to BACP’s comprehensive Ethical Framework and Professional Conduct procedure, BACP also provides all its members with access to a range of Good Practice in Action (GPiA) resources. Our GPiA resources are based on current research and evidence and reviewed by member-led focus groups and experts in the field. We provide four guidance documents that relate to the keeping of records:”

Source location

Response from BACP
Page 2 · response
Published 25 February 2025

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

Existing processes require enquiries about support networks and promptly sending mental health assessment summaries to service users’ GPs.

Verbatim wording from the response

“The Trust entirely recognises the importance of communication between its services and service users’ professional and personal support networks to support joined up care and manage risks. Service users are vital partners in their own care. However, with the exception of key support networks (such as those offered by a service user’s GP or next of kin), and although we enquire, the Trust relies on service users to expressly alert it to the involvement of any other networks. In accordance with our standard process when anyone is brought to A&E and a mental health assessment is carried out, a summary was promptly sent to Mr Holloway’s GP.”

Source location

Response from North London NHS
Page 2 · response
Published 25 February 2025

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 Trust cannot involve other relevant parties without the service user’s consent and relies on the service user identifying those parties.

Verbatim wording from the response

“The Trust was not aware that Mr Holloway had sought the support of a private therapist and was only made aware of this involvement during the inquest hearing. It appears that the therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust always seeks to involve all relevant parties in a patient’s care. However, this only possible with their consent and, although we enquire, the Trust is reliant on service users making it aware of who the relevant parties are. It is therefore difficult to see what the Trust could have done differently in this case. Notwithstanding this, the Trust will continue to reflect on this incident, which it will share through its various governance forums as part of its commitment to learning and improvement.”

Source location

Response from North London NHS
Page 2 · response
Published 25 February 2025

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

A private psychotherapist cannot currently be included in integrated care planning, limiting the ability to coordinate care across agencies.

Verbatim wording from the response

“As the psychotherapist contracted was a private practitioner there is currently no ability for them to be included in any integrated care planning that may have been available. Mr Holloway was under no obligation to inform his GP or any other care provider that he was seeking private psychotherapy. Consequently, it may have been that other agencies were unaware of this. BACP has no knowledge as to whether Mr Holloway did share this information or not.”

Source location

Response from BACP
Page 4 · response
Published 25 February 2025

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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

Existing accredited-course training and assessment requirements are considered sufficient to ensure registered members can support clients expressing suicidal ideation.

Verbatim wording from the response

“4. 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?”

Source location

Response from BACP
Page 3 · response
Published 25 February 2025

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

Existing ethical and contractual requirements, alongside client choice and practitioner judgment, are considered sufficient to govern psychotherapy record keeping.

Verbatim wording from the response

“All BACP members must adhere to BACP’s Ethical Framework.”

Source location

Response from BACP
Page 1 · response
Published 25 February 2025

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

Accredited courses teach emergency referrals and confidentiality decisions, but would not teach police contact solely on a third party’s assessment.

Verbatim wording from the response

“3. ...can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning.”

Source location

Response from BACP
Page 3 · response
Published 25 February 2025

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.3

  1. 1

    Share learning from the incident through the Trust’s governance forums to support improvement.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 February 2025.
  2. 2

    Continue reflecting on the incident through the Trust’s governance and learning processes.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 February 2025.
  3. 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 completedThe respondent said that this action was complete when they made their response on 25 February 2025.

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

Share learning from the incident through the Trust’s governance forums to support improvement.

Verbatim wording from the response

“The Trust was not aware that Mr Holloway had sought the support of a private therapist and was only made aware of this involvement during the inquest hearing. It appears that the therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust always seeks to involve all relevant parties in a patient’s care. However, this only possible with their consent and, although we enquire, the Trust is reliant on service users making it aware of who the relevant parties are. It is therefore difficult to see what the Trust could have done differently in this case. Notwithstanding this, the Trust will continue to reflect on this incident, which it will share through its various governance forums as part of its commitment to learning and improvement.”

Source location

Response from North London NHS
Page 2 · response
Published 25 February 2025

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

Continue reflecting on the incident through the Trust’s governance and learning processes.

Verbatim wording from the response

“The Trust was not aware that Mr Holloway had sought the support of a private therapist and was only made aware of this involvement during the inquest hearing. It appears that the therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust always seeks to involve all relevant parties in a patient’s care. However, this only possible with their consent and, although we enquire, the Trust is reliant on service users making it aware of who the relevant parties are. It is therefore difficult to see what the Trust could have done differently in this case. Notwithstanding this, the Trust will continue to reflect on this incident, which it will share through its various governance forums as part of its commitment to learning and improvement.”

Source location

Response from North London NHS
Page 2 · response
Published 25 February 2025

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

Require members to agree and clearly communicate service terms, confidentiality arrangements and records of agreements with clients.

Verbatim wording from the response

“Paragraph 31 covers BACP’s requirement to contract and communicate the agreed terms clearly and transparently.”

Source location

Response from BACP
Page 1 · response
Published 25 February 2025

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