PFD report

Jason Derek Vaughan · Prevention of Future Deaths report

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Issued 11 Mar 2016•South Yorkshire (Eastern)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised3

  1. Failure of the IAPT risk assessment tool to record less threatening levels of risk and deterioration over time
    Part of recurring concern: Inadequate mental health risk assessment
  2. Lack of universal recognition among mental health practitioners of suicide risk patterns in middle-aged males and socio-economic factors
    Part of recurring concern: Inadequate competence in mental health assessment
  3. Insufficient written narrative detail accompanying coded clinical record entries
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.2

  1. Action

    Deliver three workshops for IAPT teams on findings from the Confidential Inquiry into Suicides and Homicides.

    Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2016.
  2. Action

    Develop and disseminate a newsletter and Trust-wide communications message summarising suicide risk factors, including risks affecting middle-aged men.

    Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The existing IAPT risk-assessment system is considered sufficient, so the service decided not to adopt the alternative Columbia scale.

    Stated by Rotherham Doncaster and South Humber NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 the IAPT risk assessment tool to record less threatening levels of risk and deterioration over time

Wider context from the report

“(2) The existing IAPT risk assessment tool utilises a numerical rating system which has, as its starting level 1, “things feel so bad that you think about killing yourself”, and which does not allow for the recording of a less threatening position, thereby not providing a means of reflecting a deterioration, is a patient's state of risk, over time, to the current Level 1 status. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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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 universal recognition among mental health practitioners of suicide risk patterns in middle-aged males and socio-economic factors

Wider context from the report

“(3) It may not be universally recognised by all mental health practitioners, that the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2015) has identified an increasing number of suicides amongst middle aged males and also socio-economic factors becoming increasingly common in suicides. ”

Is this part of a recurring concern?

Yes — Inadequate competence in mental health assessment.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient written narrative detail accompanying coded clinical record entries

Wider context from the report

“(1) The effectiveness of the IAPT electronic patient clinical records system (SystemOne) may be limited, in some instances, by there being insufficient written narrative detail (eg. As to medication commencement dates, doses, changes etc.) to accompany the coded data entries in the drop down box selection ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Incomplete, inaccurate or unavailable clinical and care 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

Deliver three workshops for IAPT teams on findings from the Confidential Inquiry into Suicides and Homicides.

Verbatim wording from the response

“3. It may not be universally recognised by all mental health practitioners, that the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2015) has identified an increasing number of suicides amongst middle aged males and also socio-economic factors becoming increasingly common in such suicides.”

Source location

2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Page 3 · response
Published 11 March 2016

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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

Develop and disseminate a newsletter and Trust-wide communications message summarising suicide risk factors, including risks affecting middle-aged men.

Verbatim wording from the response

“In addition we have continued our overall Trust Education Programme by developing a newsletter which will go out to all mental health practitioners within the organisation summarising some of the risk factors involved in completed suicide. I have enclosed this for your information as it focuses on the issue of suicide in middle aged men. In addition this will be noted in an email that is sent from our Communications Department to all practitioners within the Trust.”

Source location

2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Page 4 · response
Published 11 March 2016

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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

The existing IAPT risk-assessment system is considered sufficient, so the service decided not to adopt the alternative Columbia scale.

Verbatim wording from the response

“The action plan highlights how the IAPT service continually appraises the effectiveness of any tools it might use. In this case the Service Managers have been actively considering an alternative tool called the ‘Columbia Suicide Severity Rating Scale’. After proper deliberation the services have elected not to use this tool because they do not believe it would offer improvements compared with the current system. Again for the avoidance of doubt, I wish to emphasise that any tool used would simply add value to robust clinical decision making based on data from a number of sources including clinical interview. We would never manage risk solely based on any tool regardless of how effective it was deemed to have been in research studies.”

Source location

2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Page 3 · response
Published 11 March 2016

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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

The SystmOne system does not have a systemic defect preventing staff from recording important medication-management information.

Verbatim wording from the response

“Electronic systems can support adequate record keeping but ultimately it still depends upon a staff member to input data. In your Regulation 28 report you gave examples regarding medications management. Recording adequate data regarding medication management is absolutely key in healthcare. This is because it is an essential part of the management of the majority of patients with severe mental disorder, and often plays a part in those with less severe mental health conditions. All medications have side effects, some of them serious. It is for this reason that I would agree with you wholeheartedly that recording adequate data regarding medications management is essential. However there does not appear to be a systemic issue with the SystmOne tool which prevents the recording of invaluable data.”

Source location

2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Page 2 · response
Published 11 March 2016

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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

Identifying middle-aged male status alone is considered insufficient to translate into a suicide-prevention intervention without other risk factors.

Verbatim wording from the response

“Although suicide is a terrible and tragic event, it is still relatively uncommon when one considers the prevalence of mental health disorder in our communities. In the scenario you asked us to focus on, namely the increased risk of suicide in middle aged men, we treat many individuals who would fall into this category. Very few of them indeed will go on to commit suicide, thank goodness. Consequently, simply identifying this factor alone would be difficult to translate into a suicide prevention act. However, this factor, along with other risk factors (e.g. substance misuse, recent life event, chronic pain condition etc) would focus practitioners on taking a particular interest in a person’s history to ensure that adequate assessment occurred.”

Source location

2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Page 4 · response
Published 11 March 2016

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

    Re-launch the Trust’s Sign up to Safety campaign, including its priority of reducing annual suicides to zero if possible.

    Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2016.

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

Re-launch the Trust’s Sign up to Safety campaign, including its priority of reducing annual suicides to zero if possible.

Verbatim wording from the response

“The Trust is part of a national movement called ‘Sign up to Safety’. The Trust has chosen five priority areas to focus on, one of them being reducing the number of annual suicides to zero if possible. We are going to re-launch this campaign having had a very successful initial start. I can provide you with details regarding this important safety intervention should you want to know more.”

Source location

2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
Page 4 · response
Published 11 March 2016

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