PFD report

Alexander George Ball · Prevention of Future Deaths report

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Issued 19 Feb 2015•Cumbria

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
12

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 raised2

  1. Lack of communication between the Partnership Trust and other agencies
  2. Absence of a dedicated Care Co-ordinator
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.10

  1. Action

    Continue inviting Cumbria Partnership NHS Foundation Trust staff to relevant serious-incident reviews to develop joint learning and clarify working practices.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2015.
  2. Action

    Continue attending frequent-attender meetings and working with partners on joined-up management of people with complex care needs.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2015.
  3. Action

    Continue organising interdisciplinary meetings with Cumbria Partnership NHS Foundation Trust to formulate care plans for people with complex care needs.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2015.

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 communication between the Partnership Trust and other agencies

Wider context from the report

“There was a lack of communication between the Partnership Trust and other agencies. The position was exacerbated by the absence of a dedicated Care Co-ordinator. ”

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

Absence of a dedicated Care Co-ordinator

Wider context from the report

“There was a lack of communication between the Partnership Trust and other agencies. The position was exacerbated by the absence of a dedicated Care Co-ordinator. ”

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

Continue inviting Cumbria Partnership NHS Foundation Trust staff to relevant serious-incident reviews to develop joint learning and clarify working practices.

Verbatim wording from the response

“Unity are actively involved in the Cumbria wide Crisis Care Concordat, a working group committed to supporting individuals experiencing a mental health crisis to get the care they need appropriately. Unity Carlisle are members of the Frequent Attenders in the Carlisle and Eden Health Economy meetings and are actively working with partners to provide a joined up approach to managing those individuals with the most complex care needs. It is usual clinical practice for Unity to attend and organise interdisciplinary team meetings with CPFT to formulate appropriate care plans for patients with complex care needs. During reviews of serious clinical incidents by Unity, it is common practice by Unity to invite team members from CPFT when appropriate. These can be opportunities to develop joint learning outcomes and to describe working practices within each organisation.”

Source location

2015-0069-Response-by-Greater-Manchester-West-NHS-Trust
Page 1 · response
Published 19 February 2015

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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

Continue attending frequent-attender meetings and working with partners on joined-up management of people with complex care needs.

Verbatim wording from the response

“Unity are actively involved in the Cumbria wide Crisis Care Concordat, a working group committed to supporting individuals experiencing a mental health crisis to get the care they need appropriately. Unity Carlisle are members of the Frequent Attenders in the Carlisle and Eden Health Economy meetings and are actively working with partners to provide a joined up approach to managing those individuals with the most complex care needs. It is usual clinical practice for Unity to attend and organise interdisciplinary team meetings with CPFT to formulate appropriate care plans for patients with complex care needs. During reviews of serious clinical incidents by Unity, it is common practice by Unity to invite team members from CPFT when appropriate. These can be opportunities to develop joint learning outcomes and to describe working practices within each organisation.”

Source location

2015-0069-Response-by-Greater-Manchester-West-NHS-Trust
Page 1 · response
Published 19 February 2015

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 organising interdisciplinary meetings with Cumbria Partnership NHS Foundation Trust to formulate care plans for people with complex care needs.

Verbatim wording from the response

“Unity are actively involved in the Cumbria wide Crisis Care Concordat, a working group committed to supporting individuals experiencing a mental health crisis to get the care they need appropriately. Unity Carlisle are members of the Frequent Attenders in the Carlisle and Eden Health Economy meetings and are actively working with partners to provide a joined up approach to managing those individuals with the most complex care needs. It is usual clinical practice for Unity to attend and organise interdisciplinary team meetings with CPFT to formulate appropriate care plans for patients with complex care needs. During reviews of serious clinical incidents by Unity, it is common practice by Unity to invite team members from CPFT when appropriate. These can be opportunities to develop joint learning outcomes and to describe working practices within each organisation.”

Source location

2015-0069-Response-by-Greater-Manchester-West-NHS-Trust
Page 1 · response
Published 19 February 2015

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

Set a maximum waiting-time measure for allocating care coordinators to patients.

Verbatim wording from the response

“With regards to the second concern you raise in respect of the lack of a permanent care coordinator, the Trust has set an internal measure relating to the maximum waiting times patients should expect for the allocation of a care co-ordinator.”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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

Actively manage the care-coordinator waiting list and undertake robust caseload reviews and supervision through clinical leads.

Verbatim wording from the response

“At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision.”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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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

Roll out the Copeland care-coordinator capacity measures across the Trust during 2015.

Verbatim wording from the response

“At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision.”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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

Use timely discharges and transfers to release capacity for allocating new cases.

Verbatim wording from the response

“At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision.”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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

Facilitate a multi-agency Oxford Learning Event to clarify and address communication pathways for people with mental health and substance misuse needs.

Verbatim wording from the response

“As detailed in the Serious Untoward Incident action plan, the Trust will facilitate an Oxford Learning Event with the identified partner agencies. The purpose of this event is to identify and address the issues of communication ensuring clarity over the pathway for clients presenting with both mental health problems and substance misuse problems across the various care groups. We plan to hold this event during June 2015 subject to agreement with partner agencies.”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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

Establish a quarterly county-wide liaison forum and report its feedback to the Clinical Governance group.

Verbatim wording from the response

“Prior to the Oxford Learning Event, I have requested that a range of immediate actions are introduced by the Trust’s Mental Health Care Group in order to improve communication arrangements with partners. These improvements include:-”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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 monthly locality meetings between Mental Health Care Group staff and local UNITY team members to provide direct communication.

Verbatim wording from the response

“Prior to the Oxford Learning Event, I have requested that a range of immediate actions are introduced by the Trust’s Mental Health Care Group in order to improve communication arrangements with partners. These improvements include:-”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 2 · response
Published 19 February 2015

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.2

  1. 1

    Continue and strengthen participation in the Cumbria-wide Crisis Care Concordat to improve crisis-care access.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2015.
  2. 2

    Complete the internal serious untoward incident investigation and provide its consequent action plan.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2015.

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 and strengthen participation in the Cumbria-wide Crisis Care Concordat to improve crisis-care access.

Verbatim wording from the response

“Unity are actively involved in the Cumbria wide Crisis Care Concordat, a working group committed to supporting individuals experiencing a mental health crisis to get the care they need appropriately. Unity Carlisle are members of the Frequent Attenders in the Carlisle and Eden Health Economy meetings and are actively working with partners to provide a joined up approach to managing those individuals with the most complex care needs. It is usual clinical practice for Unity to attend and organise interdisciplinary team meetings with CPFT to formulate appropriate care plans for patients with complex care needs. During reviews of serious clinical incidents by Unity, it is common practice by Unity to invite team members from CPFT when appropriate. These can be opportunities to develop joint learning outcomes and to describe working practices within each organisation.”

Source location

2015-0069-Response-by-Greater-Manchester-West-NHS-Trust
Page 1 · response
Published 19 February 2015

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

Complete the internal serious untoward incident investigation and provide its consequent action plan.

Verbatim wording from the response

“As acknowledged during the inquest, the Trust has undertaken significant work through the internal investigation process and the provision of the consequent action plan. Since the inquest, the Trust has reviewed the points you raised in respect of the two issues identified in the Regulation 28.”

Source location

2015-0069-Response-by-Cumbria-Partnership
Page 1 · response
Published 19 February 2015

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