PFD report

Matthew Gerard Craven · Prevention of Future Deaths report

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Issued 22 Nov 2018•Manchester South

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
5

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

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to check or understand previous engagements with Mental Health Services
  2. Failure to document the rationale for RAID decisions not to refer to a psychiatrist
    Part of recurring concern: Failure to reliably document the rationale for consequential decisions
  3. Lack of a challenge or escalation process for rejected psychiatric referrals
    Part of recurring concern: Unreliable escalation policy for care concerns
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.3

  1. Action

    Move alcohol liaison practitioners to Stepping Hill Hospital and integrate them into the all-age liaison mental health team.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 May 2019.
  2. Action

    Set a 12-week target for offering routine appointments following review with the Lead Consultant Psychiatrist.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
  3. Action

    Develop and implement a Stockport escalation process and protocol for rejected referrals and disagreements about psychiatric assessment.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.

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

  1. Position

    Evidence showed RAID planned and made a psychiatric referral, although the outpatient referral was not accepted.

    Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 check or understand previous engagements with Mental Health Services

Wider context from the report

“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust. ”

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 to document the rationale for RAID decisions not to refer to a psychiatrist

Wider context from the report

“There had been a series of attendances at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a psychiatrist. ”

Is this part of a recurring concern?

Yes — Failure to reliably document the rationale for consequential 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

Lack of a challenge or escalation process for rejected psychiatric referrals

Wider context from the report

“He had long-term anxiety. Mental Health workers assessing him had repeatedly felt he needed to be seen by a psychiatrist. The referrals were rejected by the psychiatrist. There was no challenge or escalation process within the trust to deal with the situation. ”

Is this part of a recurring concern?

Yes — Unreliable escalation policy for care concerns.

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 agreed target timescales for routine psychiatric appointments

Wider context from the report

“A routine psychiatric out patient was offered after his mother indicated she would make a formal complaint. The inquest heard that there were no agreed target timescales for the offering of routine appointments. ”

Is this part of a recurring concern?

Yes — Unreliable psychiatric appointment provision and coordination.

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 share admission and encounter information with wider mental health services

Wider context from the report

“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services.

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

Move alcohol liaison practitioners to Stepping Hill Hospital and integrate them into the all-age liaison mental health team.

Verbatim wording from the response

“Pennine Care’s alcohol liaison practitioners are moving to be based at Stepping Hill Hospital with the all age liaison mental health service and will form part of the same team which will significantly reduce the likelihood of any such concern arising again. The new model will be in place by the end of February 2019.”

Source location

2018-0365-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 10 May 2019

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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

Set a 12-week target for offering routine appointments following review with the Lead Consultant Psychiatrist.

Verbatim wording from the response

“Following review with the Lead Consultant Psychiatrist the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above.”

Source location

2018-0365-Response-by-Pennine-Care-NHS-Trust
Page 1 · response
Published 10 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 and implement a Stockport escalation process and protocol for rejected referrals and disagreements about psychiatric assessment.

Verbatim wording from the response

“We will develop a process and protocol for escalation to be used within the borough of Stockport by the end of February 2019.”

Source location

2018-0365-Response-by-Pennine-Care-NHS-Trust
Page 1 · response
Published 10 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

Evidence showed RAID planned and made a psychiatric referral, although the outpatient referral was not accepted.

Verbatim wording from the response

“3. There had been a series of presentations at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a Psychiatrist.”

Source location

2018-0365-Response-by-Pennine-Care-NHS-Trust
Page 1 · response
Published 10 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