PFD report

Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report

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Issued 16 Nov 2018•Southampton and New Forest

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
9

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised9

  1. Unclear implementation of information-sharing arrangements when patients withdraw family consent
    Part of recurring concern: Unreliable consent controls for safety-critical information sharing
  2. Insufficient staff training in implementing patient observation policies and prioritising vulnerable patients
    Part of recurring concern: Unreliable patient observation arrangements
  3. Insufficient staff training on implementing family information-sharing arrangements after consent withdrawal
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Unclear implementation of information-sharing arrangements when patients withdraw family consent

Wider context from the report

“5.4 It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented, and further training appears to be necessary. ”

Is this part of a recurring concern?

Yes — Unreliable consent controls for safety-critical information sharing.

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

Insufficient staff training in implementing patient observation policies and prioritising vulnerable patients

Wider context from the report

“5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable patients. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Insufficient staff training on implementing family information-sharing arrangements after consent withdrawal

Wider context from the report

“5.4 It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented, and further training appears to be necessary. ”

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

Unclear safeguarding requirements for vulnerable patients who are victims of crime

Wider context from the report

“5.2 Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as Eleanor Brabant and their responsibility to report those crimes to the police, whether or not the patient consented. ”

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

Unclear applicability of patient observation policies to all in-patients

Wider context from the report

“5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable patients. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Erroneous belief that informal patients cannot be detained when safety concerns arise

Wider context from the report

“5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

Is this part of a recurring concern?

Yes — Unreliable use of Mental Health Act holding powers; Unsafe application of Mental Health Act detention safeguards to informal patients.

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 of ward nurses to use section 5(4) powers to prevent unsafe patient departure

Wider context from the report

“5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

Is this part of a recurring concern?

Yes — Failure to ensure custody staff understand and apply detention procedures; Unreliable Mental Health Act detention arrangements; Unreliable use of Mental Health Act holding powers.

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

Unclear staff responsibility to report patient crimes to the police regardless of consent

Wider context from the report

“5.2 Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as Eleanor Brabant and their responsibility to report those crimes to the police, whether or not the patient consented. ”

Is this part of a recurring concern?

Yes — Unclear healthcare and police responsibilities for safety-critical action.

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

Insufficient training on Mental Health Act implementation for informal patients

Wider context from the report

“5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

Is this part of a recurring concern?

Yes — Unsafe application of Mental Health Act detention safeguards to informal patients.

Open source report
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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