PFD report

Rebecca Louise Henry · Prevention of Future Deaths report

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Issued 1 Aug 2019•Manchester West

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

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Concerns raised1

  1. Failure to communicate relevant information between mental health care professionals and patients’ close relatives
    Part of recurring concern: Failure to reliably communicate with and listen to families of mental health patientsPart of recurring concern: Unsafe confidentiality and information-sharing arrangements in service mental health care
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.1

  1. Action

    Work with professional bodies to agree and publish a consensus statement on information sharing and suicide prevention.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.

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 communicate relevant information between mental health care professionals and patients’ close relatives

Wider context from the report

“During almost 40 years sitting as a Coroner, Senior Coroner and now Assistant Coroner, I have heard numerous inquests where had there been communication between the doctors, nurses and therapists caring for patients with mental health issues, and the close relatives of those patients, many issues might have been explained and lives saved. The reason given in the present case, as in so many others, is that of patient confidentiality. Whilst the medical authorities are usually right in their interpretation, one wonders whether some form of enquiry/commission might be established to review the law on confidentiality and especially where it interfaces with those patients who have ‘capacity’ but where their relatives have valuable information which could help doctors decide on best care and treatment. ”

Is this part of a recurring concern?

Yes — Failure to reliably communicate with and listen to families of mental health patients; Unsafe confidentiality and information-sharing arrangements in service mental health care.

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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

Work with professional bodies to agree and publish a consensus statement on information sharing and suicide prevention.

Verbatim wording from the response

“The Suicide Prevention Strategy for England¹, published in 2012, placed a new emphasis on providing better support to those bereaved or affected by suicide. As part of this, the Department of Health worked with a range of professional bodies to agree a consensus view on confidentiality and suicide prevention. Information sharing and suicide prevention: Consensus statement², was published in 2014, alongside the first annual report of the suicide prevention strategy. The statement includes the following passage:”

Source location

2019-0288-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 18 October 2019

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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

    Accept the recommendation to replace the Nearest Relative provision with a patient-chosen Nominated Person.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  2. 2

    Commission and complete an independent review of the Mental Health Act and related practice.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  3. 3

    Publish a White Paper setting out the Government’s full response to the independent Mental Health Act review.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Proposed Mental Health Act changes would not have applied because the patient was not detained under the Act.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Accept the recommendation to replace the Nearest Relative provision with a patient-chosen Nominated Person.

Verbatim wording from the response

“The review did not look at confidentiality and information sharing specifically. However, it did look at the role of families and carers and made a number of recommendations, including moving from the Nearest Relative provision to Nominated Person.”

Source location

2019-0288-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 18 October 2019

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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

Commission and complete an independent review of the Mental Health Act and related practice.

Verbatim wording from the response

“You question in your report whether a review of the legal duties around patient confidentiality should take place. You may be aware, in October 2017, the Government announced plans for an independent review of mental health legislation and practice. As a first step towards this, Professor Sir Simon Wessely was asked to chair a full and independent review of the Mental Health Act. ‘Modernising the Mental Health Act: Increasing choice, reducing compulsion’³, the report of the review, was published in December 2018 and made 154 recommendations.”

Source location

2019-0288-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 18 October 2019

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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

Publish a White Paper setting out the Government’s full response to the independent Mental Health Act review.

Verbatim wording from the response

“We intend to publish a White Paper by the end of the year, which will set out the Government’s response, in full, to the independent review of the Mental Health Act, and pave the way for new legislation to be brought forward when Parliamentary time allows.”

Source location

2019-0288-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 18 October 2019

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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

Proposed Mental Health Act changes would not have applied because the patient was not detained under the Act.

Verbatim wording from the response

“As Miss Henry was not detained under the Mental Health Act, the provisions in the Act and the changes we are considering, would not have applied in this case. However, I hope it reassures you that we are taking steps to address some of the concerns which have been highlighted by this case.”

Source location

2019-0288-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 18 October 2019

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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