PFD report

Dr Debatra Sircar · Prevention of Future Deaths report

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Issued 7 Oct 2016•Inner South 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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

Described in 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.

Report evidence summary

Concerns raised3

  1. Lack of an interim care plan for patients pending Mental Health Act assessment
    Part of recurring concern: Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pendingPart of recurring concern: Unreliable interim mental health support during care transitions
  2. Failure to assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment
    Part of recurring concern: Failure to maintain clear clinical responsibility for patient carePart of recurring concern: Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pendingPart of recurring concern: Unreliable interim mental health support during care transitions
  3. Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessmentPart of recurring concern: Unreliable access to specialist mental health treatment for serious mental illness
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

    Rezone clients referred for a Mental Health Act assessment to Red until the assessment is completed.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  2. Action

    Hold thrice-weekly zoning meetings for high-risk individuals and minute agreed risk-mitigation actions.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  3. Action

    Specify the Home Treatment Team’s expected risk-management role in referrals made while clients await Mental Health Act assessment.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

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

  1. Position

    The delay in arranging the Mental Health Act assessment was not caused by an unavailable Approved Mental Health Act Practitioner.

    Stated by Oxleas 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

Lack of an interim care plan for patients pending Mental Health Act assessment

Wider context from the report

“2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period. ”

Is this part of a recurring concern?

Yes — Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending; Unreliable interim mental health support during care transitions.

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 assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment

Wider context from the report

“2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear clinical responsibility for patient care; Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending; Unreliable interim mental health support during care transitions.

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

Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment

Wider context from the report

“1. He was at risk from falls, associated with his alcohol abuse and had frequently presented in A&E department with symptoms and injuries associated with intoxication. He was unfit to be treated in the community. There appeared to be no sense of urgency in securing a bed. He was booked for a Mental Health Act (MHA) Assessment 11 days after it was advised he needed hospitalization, by which time he had died. The court was informed the delay related to the unavailability of a local authority MHA practitioner. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment; Unreliable access to specialist mental health treatment for serious mental illness.

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

Rezone clients referred for a Mental Health Act assessment to Red until the assessment is completed.

Verbatim wording from the response

“Following our review, we have instigated the following change in practice:”

Source location

2016-0352.Response-by-Oxlea-NHS-Trust
Page 2 · response
Published 19 February 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

Hold thrice-weekly zoning meetings for high-risk individuals and minute agreed risk-mitigation actions.

Verbatim wording from the response

“• Zoning meetings to review those individuals considered high risk (i.e. those in the red zone) take place three times per week and agreed actions to mitigate risks are minuted. In addition, regular weekly interface meetings between community and home treatment teams now take place to ensure that the clinical pathway between services is working properly.”

Source location

2016-0352.Response-by-Oxlea-NHS-Trust
Page 2 · response
Published 19 February 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

Specify the Home Treatment Team’s expected risk-management role in referrals made while clients await Mental Health Act assessment.

Verbatim wording from the response

“Following our review, we have instigated the following change in practice:”

Source location

2016-0352.Response-by-Oxlea-NHS-Trust
Page 2 · response
Published 19 February 2017

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 delay in arranging the Mental Health Act assessment was not caused by an unavailable Approved Mental Health Act Practitioner.

Verbatim wording from the response

“The Trust acknowledges the long period of time it took to arrange a Mental Health Act assessment however this was not, despite what the court heard, due to the unavailability of an Approved Mental Health Act Practitioner (AMHP).”

Source location

2016-0352.Response-by-Oxlea-NHS-Trust
Page 1 · response
Published 19 February 2017

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.1

  1. 1

    Hold weekly interface meetings between community and Home Treatment Teams to support the clinical pathway between services.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 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

Hold weekly interface meetings between community and Home Treatment Teams to support the clinical pathway between services.

Verbatim wording from the response

“• Zoning meetings to review those individuals considered high risk (i.e. those in the red zone) take place three times per week and agreed actions to mitigate risks are minuted. In addition, regular weekly interface meetings between community and home treatment teams now take place to ensure that the clinical pathway between services is working properly.”

Source location

2016-0352.Response-by-Oxlea-NHS-Trust
Page 2 · response
Published 19 February 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

Official responses located
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Data last updated 7 September 2026