PFD report

Amanda Jaye Briley · Prevention of Future Deaths report

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Issued 11 Nov 2019•Leicester City and South Leicestershire

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
24

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 commissioned services for autism management
    Part of recurring concern: Unreliable implementation of autism care and support services
  2. Unavailability of local inpatient mental health provision for people with autism
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
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

    Invest in specialist community teams supporting children and young people with autism and their families.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  2. Action

    Give local service providers greater budgetary control for people receiving or at risk of inpatient care.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  3. Action

    Provide specialist mental-health speech and language therapy support to Bradgate Unit wards for patients with autism.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 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

Lack of commissioned services for autism management

Wider context from the report

“The court was advised that CCG have only commissioned services in respect of the diagnosis of autism and not the management of this condition. There is no local in-patient provision and any patient with this diagnosis who requires in-patient mental health treatment would have to be placed out of area. It is a central tenet to the Winterbourne Report and the Mental Health Act Code of Practice that hospital provision should be as local as possible for individuals to maintain contact with families and communities. I ask that the CCG consider the local provision and given we are geographically so well placed, to consider (if not alone) a collaborative commissioning arrangement based on the Transforming care recommendations. ”

Is this part of a recurring concern?

Yes — Unreliable implementation of autism care and support 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

Unavailability of local inpatient mental health provision for people with autism

Wider context from the report

“The court was advised that CCG have only commissioned services in respect of the diagnosis of autism and not the management of this condition. There is no local in-patient provision and any patient with this diagnosis who requires in-patient mental health treatment would have to be placed out of area. It is a central tenet to the Winterbourne Report and the Mental Health Act Code of Practice that hospital provision should be as local as possible for individuals to maintain contact with families and communities. I ask that the CCG consider the local provision and given we are geographically so well placed, to consider (if not alone) a collaborative commissioning arrangement based on the Transforming care recommendations. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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

Invest in specialist community teams supporting children and young people with autism and their families.

Verbatim wording from the response

“• Investment in specialist community teams to help support children and young people with autism and their families.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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

Give local service providers greater budgetary control for people receiving or at risk of inpatient care.

Verbatim wording from the response

“• Local service providers will be given more control of budgets for people who are in inpatient care, or who are at risk of it to help them spend the money on support in the community, make stays in inpatient services shorter and stop out of area placements.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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

Provide specialist mental-health speech and language therapy support to Bradgate Unit wards for patients with autism.

Verbatim wording from the response

“In the interim the Directorate has identified some specialist mental health SLT resource. The individuals providing this support to the wards at the Bradgate Unit are skilled in ASD diagnosis and management. All in-patients with a diagnosis of ASD will be referred to the SLT service to ensure the care plans reflect a bespoke and differentiated approach. In addition the SLTs are looking at the best ways to support ward staff and are working with the OTs to develop a decision making flowchart. Again the feedback from Ms Briley’s mum will inform this tool.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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 a multidisciplinary decision-making flowchart to support ward staff caring for patients with autism.

Verbatim wording from the response

“In the interim the Directorate has identified some specialist mental health SLT resource. The individuals providing this support to the wards at the Bradgate Unit are skilled in ASD diagnosis and management. All in-patients with a diagnosis of ASD will be referred to the SLT service to ensure the care plans reflect a bespoke and differentiated approach. In addition the SLTs are looking at the best ways to support ward staff and are working with the OTs to develop a decision making flowchart. Again the feedback from Ms Briley’s mum will inform this tool.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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

Refer all inpatients diagnosed with autism to speech and language therapy so care plans reflect bespoke, differentiated needs.

Verbatim wording from the response

“In the interim the Directorate has identified some specialist mental health SLT resource. The individuals providing this support to the wards at the Bradgate Unit are skilled in ASD diagnosis and management. All in-patients with a diagnosis of ASD will be referred to the SLT service to ensure the care plans reflect a bespoke and differentiated approach. In addition the SLTs are looking at the best ways to support ward staff and are working with the OTs to develop a decision making flowchart. Again the feedback from Ms Briley’s mum will inform this tool.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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.19

  1. 1

    Work with the wider NHS to improve understanding of autism.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  2. 2

    Provide keyworkers to coordinate support for children and young people with the most complex needs.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  3. 3

    Provide children and young people in special and residential schools with improved access to hearing, sight and dental checks.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  4. 4

    Reduce waiting times for autism diagnosis.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  5. 5

    Provide additional funding to crisis and forensic services for people at risk of inpatient admission or who have committed a crime.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  6. 6

    Apply Care and Treatment Review and Care Education Treatment Review requirements to autistic people at risk of admission or living in hospital.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
  7. 7

    Pilot annual health checks and flag reasonable adjustments on health records.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  8. 8

    Increase use of Personal Health Budgets to give people more choice and control over support.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  9. 9

    Continue the Care (Education) and Treatment Review programme.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
  10. 10

    Continue STOMP and STOMP-STAMP programmes addressing inappropriate medication use.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
  11. 11

    Make autism training role-essential for clinical staff in adult mental health and learning disability services.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  12. 12

    Deliver practical training on recognising and caring for people with autistic spectrum disorders.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
  13. 13

    Strengthen bank-holiday handovers through clarified staff expectations and senior nurse checks.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
  14. 14

    Develop a programme for checking ward handovers.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  15. 15

    Develop more in-depth autism training for inpatient mental health areas through a multidisciplinary task-and-finish group.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  16. 16

    Review the Handover Policy and documentation.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  17. 17

    Review Trust training provision for autistic spectrum disorders.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
  18. 18

    Introduce Nerve Centre handheld access to current patient information and handovers in mental health and learning disability wards.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  19. 19

    Provide an Autism Awareness e-learning module accessible to all staff.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.

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

  1. 1

    A central specialist-placement register is not workable because appropriate placements require individual assessment and case-by-case dialogue with providers.

    Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 the wider NHS to improve understanding of autism.

Verbatim wording from the response

“• There will be work with the wider NHS to improve understanding of autism.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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

Provide keyworkers to coordinate support for children and young people with the most complex needs.

Verbatim wording from the response

“In addition, in January 2019 NHS England published its ‘Long-Term Plan’, which highlights autism as one of the key priorities for the next ten years. The Long-Term Plan identifies the following areas of focus for autistic people:”

Source location

2019-0021-Response-by-NHS-England
Page 2 · response
Published 23 May 2019

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

Provide children and young people in special and residential schools with improved access to hearing, sight and dental checks.

Verbatim wording from the response

“In addition, in January 2019 NHS England published its ‘Long-Term Plan’, which highlights autism as one of the key priorities for the next ten years. The Long-Term Plan identifies the following areas of focus for autistic people:”

Source location

2019-0021-Response-by-NHS-England
Page 2 · response
Published 23 May 2019

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

Reduce waiting times for autism diagnosis.

Verbatim wording from the response

“In addition, in January 2019 NHS England published its ‘Long-Term Plan’, which highlights autism as one of the key priorities for the next ten years. The Long-Term Plan identifies the following areas of focus for autistic people:”

Source location

2019-0021-Response-by-NHS-England
Page 2 · response
Published 23 May 2019

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

Provide additional funding to crisis and forensic services for people at risk of inpatient admission or who have committed a crime.

Verbatim wording from the response

“• More money will be given to crisis and forensic services for those at risk of admission to inpatient services, or who have committed a crime.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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

Apply Care and Treatment Review and Care Education Treatment Review requirements to autistic people at risk of admission or living in hospital.

Verbatim wording from the response

“To this regard I can confirm that in October 2015 NHS England published its Care and Treatment Review (CTR) policy and guidelines which were developed as part of a commitment to improve the care of people with learning disabilities in England, and its aims to reduce inappropriate admissions, and unnecessarily lengthy stays in learning disability and mental health hospitals.”

Source location

2019-0021-Response-by-NHS-England
Page 2 · response
Published 23 May 2019

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

Pilot annual health checks and flag reasonable adjustments on health records.

Verbatim wording from the response

“• Piloting of annual health checks and flagging of reasonable adjustments on health records.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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

Increase use of Personal Health Budgets to give people more choice and control over support.

Verbatim wording from the response

“• The use of more Personal Health Budgets to give people more choice and control over how they are supported.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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 the Care (Education) and Treatment Review programme.

Verbatim wording from the response

“CTR meetings review whether a person is receiving the appropriate care and treatment and make recommendations for future care and treatment. CTRs are designed to ensure the voice of the person and their family are listened to, and they are chaired by the responsible commissioner with external input from appropriate clinical experts. CTRs can happen in the community when someone is at risk of admission to a learning disability or mental health hospital, or they happen once someone is admitted to a learning disability or mental health hospital.”

Source location

2019-0021-Response-by-NHS-England
Page 2 · response
Published 23 May 2019

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 STOMP and STOMP-STAMP programmes addressing inappropriate medication use.

Verbatim wording from the response

“• The ‘STOMP’: Stopping the over-medication of people with a learning disability, autism or both, and ‘STOMP-STAMP’: Supporting Treatment and Appropriate Medication in Paediatrics programmes will continue.”

Source location

2019-0021-Response-by-NHS-England
Page 3 · response
Published 23 May 2019

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

Make autism training role-essential for clinical staff in adult mental health and learning disability services.

Verbatim wording from the response

“████████, Head of Nursing and ████████, Director for Adult Mental Health and Learning Disability Services have reviewed the Trust training provision. The Trust introduced an e-learning Autism Awareness module in November 2017 which is accessible to all staff. A recommendation went to the Trust Learning and Development group in February 2018 that this training becomes role essential for clinical staff in AMH/LD Services; this was agreed and will be finalised at the Trust’s Strategic Workforce Group in March 2019.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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

Deliver practical training on recognising and caring for people with autistic spectrum disorders.

Verbatim wording from the response

“In March 2018 a Recognising and Caring for People with Autistic Spectrum Disorders (ASD) practical workshop took place involving a range of professionals with experience of working with people with autism, ████████ a Speech and Language Therapists (SLT) Assistant, and Consultants from the Autism Diagnostic Service and Learning Disability Service. The Trust is currently looking at how to develop this training further for inpatient areas that will be working with patients with ASD in Mental Health Services. A training task and finish group has been set up with representatives from mental health wards, learning disability services, SLT and Occupational Therapy (OT) to develop a more in depth training product and this will be reporting back to the Directorate Management Team in April 2019.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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

Strengthen bank-holiday handovers through clarified staff expectations and senior nurse checks.

Verbatim wording from the response

“Ms Briley’s request was just before the Christmas bank holiday period and immediate action was taken by the Heads of Nursing across the Trust to ensure the working arrangements and expectations of staff around the handover of patient care was clear during this period. On the wards at the Bradgate Unit there is a senior nurse on duty as the ‘Clinical Duty Manager’ (CDM) at all times (24 hours, 7 days a week). The CDM visited wards over the Christmas and New Year period to ensure handovers were taking place appropriately.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 23 May 2019

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 a programme for checking ward handovers.

Verbatim wording from the response

“In January 2019 the learning from Ms Briley’s death and the inquest was discussed again at the Chief Nurse’s meeting with all Heads of Nursing and as a result the Trust’s Handover Policy and documentation will be reviewed and a further programme of checking of handovers on wards will be developed. In April 2019 the Mental Health and Learning Disability Wards will commence introducing Nerve Centre which enables each staff member on duty to carry a hand-held device allowing them immediate access to a set of patient information including the latest handover for that patient. Staff members can directly add information about the patients care whilst with the patient, which then provides an automatic update to the central information for that patient held on Nerve Centre so all users can see any changes to care immediately.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 23 May 2019

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 more in-depth autism training for inpatient mental health areas through a multidisciplinary task-and-finish group.

Verbatim wording from the response

“In March 2018 a Recognising and Caring for People with Autistic Spectrum Disorders (ASD) practical workshop took place involving a range of professionals with experience of working with people with autism, ████████ a Speech and Language Therapists (SLT) Assistant, and Consultants from the Autism Diagnostic Service and Learning Disability Service. The Trust is currently looking at how to develop this training further for inpatient areas that will be working with patients with ASD in Mental Health Services. A training task and finish group has been set up with representatives from mental health wards, learning disability services, SLT and Occupational Therapy (OT) to develop a more in depth training product and this will be reporting back to the Directorate Management Team in April 2019.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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 the Handover Policy and documentation.

Verbatim wording from the response

“In January 2019 the learning from Ms Briley’s death and the inquest was discussed again at the Chief Nurse’s meeting with all Heads of Nursing and as a result the Trust’s Handover Policy and documentation will be reviewed and a further programme of checking of handovers on wards will be developed. In April 2019 the Mental Health and Learning Disability Wards will commence introducing Nerve Centre which enables each staff member on duty to carry a hand-held device allowing them immediate access to a set of patient information including the latest handover for that patient. Staff members can directly add information about the patients care whilst with the patient, which then provides an automatic update to the central information for that patient held on Nerve Centre so all users can see any changes to care immediately.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 23 May 2019

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 Trust training provision for autistic spectrum disorders.

Verbatim wording from the response

“████████, Head of Nursing and ████████, Director for Adult Mental Health and Learning Disability Services have reviewed the Trust training provision. The Trust introduced an e-learning Autism Awareness module in November 2017 which is accessible to all staff. A recommendation went to the Trust Learning and Development group in February 2018 that this training becomes role essential for clinical staff in AMH/LD Services; this was agreed and will be finalised at the Trust’s Strategic Workforce Group in March 2019.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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

Introduce Nerve Centre handheld access to current patient information and handovers in mental health and learning disability wards.

Verbatim wording from the response

“In January 2019 the learning from Ms Briley’s death and the inquest was discussed again at the Chief Nurse’s meeting with all Heads of Nursing and as a result the Trust’s Handover Policy and documentation will be reviewed and a further programme of checking of handovers on wards will be developed. In April 2019 the Mental Health and Learning Disability Wards will commence introducing Nerve Centre which enables each staff member on duty to carry a hand-held device allowing them immediate access to a set of patient information including the latest handover for that patient. Staff members can directly add information about the patients care whilst with the patient, which then provides an automatic update to the central information for that patient held on Nerve Centre so all users can see any changes to care immediately.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 3 · response
Published 23 May 2019

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

Provide an Autism Awareness e-learning module accessible to all staff.

Verbatim wording from the response

“████████, Head of Nursing and ████████, Director for Adult Mental Health and Learning Disability Services have reviewed the Trust training provision. The Trust introduced an e-learning Autism Awareness module in November 2017 which is accessible to all staff. A recommendation went to the Trust Learning and Development group in February 2018 that this training becomes role essential for clinical staff in AMH/LD Services; this was agreed and will be finalised at the Trust’s Strategic Workforce Group in March 2019.”

Source location

Response from Leicestershire Partnership NHS Trust
Page 2 · response
Published 23 May 2019

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

A central specialist-placement register is not workable because appropriate placements require individual assessment and case-by-case dialogue with providers.

Verbatim wording from the response

“I must advise however that a central register does not exist within the NHS and the closest comparison is this CQC list. Ultimately a central register is not workable as there will always be a need for an individual assessment and dialogue with providers”

Source location

2019-0021-Response-by-NHS-England
Page 1 · response
Published 23 May 2019

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