PFD report

Name not published · Prevention of Future Deaths report

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Issued 21 Dec 2018•Shropshire, Telford and Wrekin

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 accurately record progress notes and risk assessments
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable documentation of safety risk assessments
  2. Delays in access to IAPT counselling
    Part of recurring concern: Excessive waiting times for NHS mental health services
  3. Failure to define the updating and use of risk assessments with progress notes
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.7

  1. Action

    Redesign IAPT counselling as a locality-based model with increased capacity and flexibility to respond to demand and staffing changes.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
  2. Action

    Update Rio form guidance to show staff how to find the history of electronic record entries.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
  3. Action

    Develop the Rio system further to make exact changes between versions of electronic records identifiable.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.

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

  1. Position

    Automatic validation of all electronic records is not achievable because some staff entries must be validated by other staff.

    Stated by Midlands Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 accurately record progress notes and risk assessments

Wider context from the report

“2. Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable documentation of safety risk 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

Delays in access to IAPT counselling

Wider context from the report

“1 Delay in IAPT counselling a) After ████████ turned 18 she moved to adult mental health services. She had parallel contact with her GP surgery ████████. Shortly before her 18th birthday, according to the MPFT clinical review (page 9 of 33), ████████ was referred to Improving Access to Psychological Therapies (IAPT) by the ████████ Access Team for assessment for psychological therapy or counselling. On the 14th November 2017 (page 12 of 33) it was agreed with ████████ to add her to her GP surgery waiting list for counselling in line with her treatment preference. ████████ remained on the IAPT waiting list for counselling at the time of her death. b) The evidence at the inquest was that a 3 month time interval would be optimal but in ████████ case, in relation to this GP surgery, 10 months would be the norm. Such a delay is sub-optimal and could have an adverse effect on a patient waiting for counselling to commence. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services.

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 define the updating and use of risk assessments with progress notes

Wider context from the report

“2. Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved. ”

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

Failure of electronic records to preserve and clearly display original entries

Wider context from the report

“2. Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Unreliable traceability of retrospective amendments to safety records.

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

Redesign IAPT counselling as a locality-based model with increased capacity and flexibility to respond to demand and staffing changes.

Verbatim wording from the response

“The revised model eligibility criteria will give the IAPT service increased capacity, enabling greater flexibility with regard to where and when people can be seen. A 3-month transioperiod is currently underway during which a redesign of the IAPT service is taking place, whereby counselling provision will be more consistently provided across the county from a locality based model, which is more efficient and therefore it will be more possible to be flexible in responding to changes in supply of staff to meet changes in demand thus reducing waiting times to within the statutory 18 week target. It is anticipated that once this work is completed, planned within a six month timescale, it will then be possible to keep waiting times within these recommended limits.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 2 · response
Published 31 May 2024

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

Update Rio form guidance to show staff how to find the history of electronic record entries.

Verbatim wording from the response

“The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 2 · response
Published 31 May 2024

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

Develop the Rio system further to make exact changes between versions of electronic records identifiable.

Verbatim wording from the response

“The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 2 · response
Published 31 May 2024

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

Update Trust policies and procedures for clinical risk assessment and management, including minimum six-monthly and significant-change reviews.

Verbatim wording from the response

“Since we became a new Trust in June 2018 our services have expanded considerably leading to a review of all Trust Policies and Procedures. We are currently updating our policies and procedures for Clinical Risk Assessment and Management. The new policy will go to Trust Board in March 2019 and includes the directive that all risk assessments must be reviewed as a minimum once every six months and/or when there is any significant change in presentation. In addition, to complement the policy, we are developing a number of Standard Operating Procedures (SOPs) for specific services which includes one for mental health services and effective utilisation of the FACE risk assessment tool.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 3 · response
Published 31 May 2024

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

Remind staff to validate records and routinely audit unvalidated notes, providing audit feedback to clinical teams.

Verbatim wording from the response

“validated by others. We have issued a reminder to staff to validate their records and a regular audit of un-validated notes is undertaken with feedback of the audit outcome being sent to the clinical teams.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 3 · response
Published 31 May 2024

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 mandatory clinical risk management training to cover the revised mental-health risk assessment and management procedures.

Verbatim wording from the response

“The SOP describes how the FACE Tool is used to gather information about risk, both current and historical, and then to use this information in formulation which is an evidence based clinical decision making process enabling a robust risk management plan to be developed specifically addressing the individual patient’s needs. This risk management plan will then be incorporated into the patient’s overall care plan. Monitoring of this care plan is through the patient’s progress notes. When there is a significant change in presentation the risk assessment is re-evaluated, risk management plan updated and reference made to this in the progress notes. In order to ensure that staff are competent in this process, the clinical risk management training, which is mandatory for all clinical staff to complete every 3 years, will cover the revised Standard Operating Procedures.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 3 · response
Published 31 May 2024

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

Develop and obtain ratification for a mental-health Standard Operating Procedure covering use of the FACE risk assessment tool.

Verbatim wording from the response

“Since we became a new Trust in June 2018 our services have expanded considerably leading to a review of all Trust Policies and Procedures. We are currently updating our policies and procedures for Clinical Risk Assessment and Management. The new policy will go to Trust Board in March 2019 and includes the directive that all risk assessments must be reviewed as a minimum once every six months and/or when there is any significant change in presentation. In addition, to complement the policy, we are developing a number of Standard Operating Procedures (SOPs) for specific services which includes one for mental health services and effective utilisation of the FACE risk assessment tool.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 3 · response
Published 31 May 2024

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

Automatic validation of all electronic records is not achievable because some staff entries must be validated by other staff.

Verbatim wording from the response

“In regard to the validation of notes, legally it is only students who must have their records validated by a qualified member of staff. All other staff are required to validate their own entries. The action of validating the entry represents the electronic signature of the accuracy and confirmation of that entry. The Trust has explored with our healthcare information colleagues whether the default could be an automatic validation which is then “unticked” but this is not achievable given that some staff must have their entries”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 2 · response
Published 31 May 2024

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

    Centralise countywide GP counselling provision through IAPT under the revised commissioning arrangements.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.

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

Centralise countywide GP counselling provision through IAPT under the revised commissioning arrangements.

Verbatim wording from the response

“Historically, counselling provision ████████ has been provided from a practice-based model and commissioned from a number of providers, including IAPT. Since January 2019 the commissioning arrangements for GP counselling ████████ have been changed, so that IAPT will infuture provide all counselling provision across the county. The existing provision is person centred inorientation where the patient will be given information and then decide where they would prefer to be seen.”

Source location

Response from Midlands Partnership NHS Foundation Trust
Page 2 · response
Published 31 May 2024

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