PFD report

Paul Leslie HYDE · Prevention of Future Deaths report

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Issued 5 Dec 2014•Brighton and Hove

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
6

Raised in this report

Recipients
2

Named on the report

Responses found
1

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 raised6

  1. Delays in appropriately addressing referrals within the 28-day period
    Part of recurring concern: Failure to complete timely direct mental health assessments after referralPart of recurring concern: Unreliable mental health referral pathways
  2. Failure to contact the GP about the referral
    Part of recurring concern: Failure to provide sufficient GP involvement in patient carePart of recurring concern: Failure to reliably escalate patient safety concerns to primary care
  3. Poor documentation of referral-management decisions
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable documentation and communication of shared clinical decisions
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

    Strengthen clinical triage meetings through Consultant Psychiatrist, lead nurse, administrator and additional specialist participation.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
  2. Action

    Recruit an additional triage administrator.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
  3. Action

    Allocate named Consultant Psychiatrists to GPs and arrange meetings to clarify referral roles and expectations.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.

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 appropriately addressing referrals within the 28-day period

Wider context from the report

“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

Is this part of a recurring concern?

Yes — Failure to complete timely direct mental health assessments after referral; Unreliable mental health referral pathways.

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 contact the GP about the referral

Wider context from the report

“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

Is this part of a recurring concern?

Yes — Failure to provide sufficient GP involvement in patient care; Failure to reliably escalate patient safety concerns to primary 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

Poor documentation of referral-management decisions

Wider context from the report

“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable documentation and communication of shared clinical decisions.

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 face-to-face psychiatric medication reviews

Wider context from the report

“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews.

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 referral follow-up system

Wider context from the report

“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up; Failure to provide timely continuing mental health reviews and follow-up.

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 facility for psychiatrists to participate in assessment and determine a course of treatment

Wider context from the report

“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Strengthen clinical triage meetings through Consultant Psychiatrist, lead nurse, administrator and additional specialist participation.

Verbatim wording from the response

“████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014

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

Recruit an additional triage administrator.

Verbatim wording from the response

“████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014

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

Allocate named Consultant Psychiatrists to GPs and arrange meetings to clarify referral roles and expectations.

Verbatim wording from the response

“We are always striving to improve the interface between primary care and secondary mental health services. In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists. Meetings between the psychiatrists and GPs have been arranged. ████████ is leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals. Work is on-going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement. Mr Hyde’s experience has been shared (anonymously) with staff to drive home the lessons to be learned. In addition, to ensure widespread learning, feedback from the case has been given to ████████ Director of Nursing Standards and Safety.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 2 · response
Published 5 December 2014

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

Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.

Verbatim wording from the response

“The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014

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

Review administration triage processes to reduce triage waiting times.

Verbatim wording from the response

“████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014

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.5

  1. 1

    Develop a joined-up approach between primary and secondary mental health services for service users and families.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 December 2014.
  2. 2

    Continue monthly performance reviews with commissioners and maintain an updated referral-management action plan.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 December 2014.
  3. 3

    Disseminate anonymised lessons from Mr Hyde’s experience to staff, nursing safety leadership and the Quarterly Quality & Patient Safety Report.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
  4. 4

    Review ATS referral-management data with commissioners and clinical leads to ensure triage decisions are clinically led and appropriate.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
  5. 5

    Audit triage outcome decisions quarterly with an independent senior clinician.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 December 2014.

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

  1. 1

    Adult Social Care & Health had no specific role in Mr Hyde’s care and therefore was outside the relevant responsibility.

    Stated by Sussex Partnership NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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

Develop a joined-up approach between primary and secondary mental health services for service users and families.

Verbatim wording from the response

“We are always striving to improve the interface between primary care and secondary mental health services. In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists. Meetings between the psychiatrists and GPs have been arranged. ████████ is leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals. Work is on-going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement. Mr Hyde’s experience has been shared (anonymously) with staff to drive home the lessons to be learned. In addition, to ensure widespread learning, feedback from the case has been given to ████████ Director of Nursing Standards and Safety.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 2 · response
Published 5 December 2014

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 monthly performance reviews with commissioners and maintain an updated referral-management action plan.

Verbatim wording from the response

“A meeting with the CCG Clinical Lead, Sussex Partnership Clinical Lead for Community Services and Sussex Partnership Managers was held to review the ATS data to ensure all actions relating to referral management are clinically led and appropriate. In addition, ████████ Service Manager for the Assessment & Treatment Service for Brighton & Hove has agreed to undertake a quarterly audit of the triage outcome decisions, with an independent senior clinician, to ensure triage decisions are appropriate. We continue to discuss and review our performance against key performance indicators with commissioners on a monthly basis and maintain an updated action plan to ensure this remains a continual focus for quality improvement.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 2 · response
Published 5 December 2014

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

Disseminate anonymised lessons from Mr Hyde’s experience to staff, nursing safety leadership and the Quarterly Quality & Patient Safety Report.

Verbatim wording from the response

“We are always striving to improve the interface between primary care and secondary mental health services. In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists. Meetings between the psychiatrists and GPs have been arranged. ████████ is leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals. Work is on-going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement. Mr Hyde’s experience has been shared (anonymously) with staff to drive home the lessons to be learned. In addition, to ensure widespread learning, feedback from the case has been given to ████████ Director of Nursing Standards and Safety.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 2 · response
Published 5 December 2014

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

Review ATS referral-management data with commissioners and clinical leads to ensure triage decisions are clinically led and appropriate.

Verbatim wording from the response

“A meeting with the CCG Clinical Lead, Sussex Partnership Clinical Lead for Community Services and Sussex Partnership Managers was held to review the ATS data to ensure all actions relating to referral management are clinically led and appropriate. In addition, ████████ Service Manager for the Assessment & Treatment Service for Brighton & Hove has agreed to undertake a quarterly audit of the triage outcome decisions, with an independent senior clinician, to ensure triage decisions are appropriate. We continue to discuss and review our performance against key performance indicators with commissioners on a monthly basis and maintain an updated action plan to ensure this remains a continual focus for quality improvement.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 2 · response
Published 5 December 2014

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

Audit triage outcome decisions quarterly with an independent senior clinician.

Verbatim wording from the response

“A meeting with the CCG Clinical Lead, Sussex Partnership Clinical Lead for Community Services and Sussex Partnership Managers was held to review the ATS data to ensure all actions relating to referral management are clinically led and appropriate. In addition, ████████ Service Manager for the Assessment & Treatment Service for Brighton & Hove has agreed to undertake a quarterly audit of the triage outcome decisions, with an independent senior clinician, to ensure triage decisions are appropriate. We continue to discuss and review our performance against key performance indicators with commissioners on a monthly basis and maintain an updated action plan to ensure this remains a continual focus for quality improvement.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 2 · response
Published 5 December 2014

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

Adult Social Care & Health had no specific role in Mr Hyde’s care and therefore was outside the relevant responsibility.

Verbatim wording from the response

“████████ and myself have taken the matters you have raised extremely seriously, and seek to reassure you that work has been undertaken, and is on-going, to improve practice in Sussex Partnership NHS Foundation Trust. This letter is a joint response from all recipients. The letter was directed to the City Council and although mental health services in Brighton and Hove are integrated with the Council there was no specific role identified for Adult Social Care & Health in Mr Hyde’s care.”

Source location

2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014

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