PFD report

Lynsey Ellen Dearden · Prevention of Future Deaths report

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Issued 18 Nov 2025•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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

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 complete standard community needs and treatment assessments
    Part of recurring concern: Failure to provide reliable community mental health assessmentsPart of recurring concern: Untimely or incomplete community care assessments
  2. Failure to provide appointments from allocated Community Psychiatric Nurses and key workers
    Part of recurring concern: Unreliable Community Mental Health care access and discharge processes
  3. Lack of policy, guidance or framework governing standard community needs and treatment assessments
    Part of recurring concern: Failure to provide reliable community mental health assessments
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.3

  1. Action

    Monitor adoption of the Practice Note and appointment timescales through multidisciplinary-team and assurance audits, including scheduled follow-up audits.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2025.
  2. Action

    Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  3. Action

    Revise the Trust Care Management Policy to incorporate the new processes, guidance, and audit assurance arrangements.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2025.

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 standard community needs and treatment assessments

Wider context from the report

“2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this. ”

Is this part of a recurring concern?

Yes — Failure to provide reliable community mental health assessments; Untimely or incomplete community care assessments.

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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 provide appointments from allocated Community Psychiatric Nurses and key workers

Wider context from the report

“1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place; ”

Is this part of a recurring concern?

Yes — Unreliable Community Mental Health care access and discharge processes.

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 policy, guidance or framework governing standard community needs and treatment assessments

Wider context from the report

“2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this. ”

Is this part of a recurring concern?

Yes — Failure to provide reliable community mental health assessments.

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 policy or procedure governing the timing and conduct of appointments

Wider context from the report

“1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place; ”

Is this part of a recurring concern?

Yes — Unreliable psychiatric appointment provision and coordination.

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

Monitor adoption of the Practice Note and appointment timescales through multidisciplinary-team and assurance audits, including scheduled follow-up audits.

Verbatim wording from the response

“The Practice Note already referenced has been issued to all relevant senior leads with an expectation that the improvements are immediately operational. Timeframes have been agreed and will be monitored via multidisciplinary team and assurance audits. Two initial audits have been undertaken, one prior to the Christmas 2025 and one during the second week of January 2026 to assess the adoption of the Practice Note and expected timescales. Results indicate good compliance across the Inpatient, CRHTT and CMHT services. A further audit is scheduled for 3 months’ time and 12-18 months to provide assurance that these processes have been embedded.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 2 · response
Published 21 November 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

Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.

Verbatim wording from the response

“Immediate actions taken: In response to the PFD and our internal review, we have implemented the following: A Practice Note issued highlighting the following,”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 2 · response
Published 21 November 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

Revise the Trust Care Management Policy to incorporate the new processes, guidance, and audit assurance arrangements.

Verbatim wording from the response

“These additional processes and clarifications will be added to the Trust Care Management Policy which is currently under review.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 2 · response
Published 21 November 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.7

  1. 1

    Provide staff training on person-centred care, therapeutic relationships, and co-production in care planning.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  2. 2

    Transition care planning to a co-produced, person-centred approach aligned with Professional Record Standards and current national guidance.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2025.
  3. 3

    Introduce a Standard Operating Procedure for care planning.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  4. 4

    Discuss all Regulation 28 reports through the Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  5. 5

    Share the draft Personalised Care Framework with systems to support early adoption.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  6. 6

    Share learning and insights from Regulation 28 reports across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  7. 7

    Continue working with systems to improve Mental Health Services Data Set submissions for community mental health waiting-time measures.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 21 November 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

Provide staff training on person-centred care, therapeutic relationships, and co-production in care planning.

Verbatim wording from the response

“Our new way of care planning is in line with the Professional Record Standards Body and was guided by the NHSE Community Mental Health Framework initially and now by the NHSE Comprehensive Model of Personalised Care, to ensure a consistent framework is being followed across the Trust. As a result of this, our staff have received care planning training which has focused on person centred care, the values of a therapeutic relationship and coproduction. We have a new Standard Operating Procedure for care planning and are drafting our Care Management Policy currently to reflect these changes in practice and guidance.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 3 · response
Published 21 November 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

Transition care planning to a co-produced, person-centred approach aligned with Professional Record Standards and current national guidance.

Verbatim wording from the response

“In addition, it is pertinent to explain that the Trust has undertaken work to transition to co-produced care planning and move away from Care Programme Approach (CPA) as this was a large-scale transformation project, this has been delivered in phases across the Trust. Our aim is to align all care planning to ensure coproduced person-centred care for our service users and consistency for staff when developing care plans. This will mean one way to complete care planning for all service users.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 3 · response
Published 21 November 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

Introduce a Standard Operating Procedure for care planning.

Verbatim wording from the response

“Our new way of care planning is in line with the Professional Record Standards Body and was guided by the NHSE Community Mental Health Framework initially and now by the NHSE Comprehensive Model of Personalised Care, to ensure a consistent framework is being followed across the Trust. As a result of this, our staff have received care planning training which has focused on person centred care, the values of a therapeutic relationship and coproduction. We have a new Standard Operating Procedure for care planning and are drafting our Care Management Policy currently to reflect these changes in practice and guidance.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 3 · response
Published 21 November 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

Discuss all Regulation 28 reports through the Regulation 28 Working Group.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lynsey, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 21 November 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

Share the draft Personalised Care Framework with systems to support early adoption.

Verbatim wording from the response

“NHS England continues to support systems to improve care for people with mental health problems needing help from secondary mental health services. NHS England has shared draft guidance with systems, the Personalised Care Framework, that sets out the core aspects of care for people who require help from secondary or integrated primary care services, the Voluntary Community and Social Enterprise (VCSE) and secondary care mental health services. The draft has been shared to facilitate early adoption.”

Source location

Response from NHS England
Page 1 · response
Published 21 November 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

Share learning and insights from Regulation 28 reports across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lynsey, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 21 November 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 working with systems to improve Mental Health Services Data Set submissions for community mental health waiting-time measures.

Verbatim wording from the response

“This builds upon the groundwork laid through the increased investment in services, alongside the development of new waiting times measures for accessing community mental health services. NHS England also continues to work with systems to improve the data quality of the Mental Health Services Data Set (MHSDS) submissions for this measure, which records how many people receive meaningful help within 4 weeks of referral.”

Source location

Response from NHS England
Page 2 · response
Published 21 November 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