PFD report

Louise Dawn Locke · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 29 Jan 2016•Central Hampshire

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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised7

  1. Lack of an adequate system to collate and assess information from other agencies
  2. Failure to provide a consistent suicide prevention approach across service areas
    Part of recurring concern: Inconsistent implementation of suicide-prevention systems
  3. Failure to apply a multi-agency approach to high-risk individuals in Winchester
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

    Communicate through RCA learning events that risk assessments must occur before discharge.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2016.
  2. Action

    Flag repeated emergency-department self-harm or overdose presentations to the Acute Mental Health Team for multidisciplinary safety and risk review.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2016.
  3. Action

    Collate and share information from agencies about people with frequent or escalating contact through High Intensity User Groups.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 January 2016.

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 an adequate system to collate and assess information from other agencies

Wider context from the report

“(2) There was no adequate system in place to collate and assess information from other agencies such that her risk profile could be reviewed and appropriate support offered ”

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 provide a consistent suicide prevention approach across service areas

Wider context from the report

“(3) The systems already in place in some parts of Hampshire for a multi-agency approach to high risk individuals do not apply in Winchester and so opportunities to recognise these people are being missed. There should be a consistent approach by Southern Health to suicide prevention across all of the areas it serves. ”

Is this part of a recurring concern?

Yes — Inconsistent implementation of suicide-prevention systems.

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 apply a multi-agency approach to high-risk individuals in Winchester

Wider context from the report

“(3) The systems already in place in some parts of Hampshire for a multi-agency approach to high risk individuals do not apply in Winchester and so opportunities to recognise these people are being missed. There should be a consistent approach by Southern Health to suicide prevention across all of the areas it serves. ”

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 carry out proper risk assessments before discharge

Wider context from the report

“(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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 offer adequate support at discharge

Wider context from the report

“(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support ”

Is this part of a recurring concern?

Yes — Unsafe discharge, closure or withdrawal of 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

Premature discharge from community mental health services

Wider context from the report

“(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support ”

Is this part of a recurring concern?

Yes — Unreliable Community Mental Health care access and discharge processes; Unsafe discharge, closure or withdrawal of 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 review risk profiles and offer appropriate support

Wider context from the report

“(2) There was no adequate system in place to collate and assess information from other agencies such that her risk profile could be reviewed and appropriate support offered ”

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

Communicate through RCA learning events that risk assessments must occur before discharge.

Verbatim wording from the response

“These plans will be brought back to the Clinical Director ████████ for sign off on the 21st April at the directors meeting. Risk assessments should take place prior to any discharge and this has been communicated through all learning events related to this RCA. The disengagement policy will be amended to reflect the process to follow disengagement from a second opinion.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 29 January 2016

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

Flag repeated emergency-department self-harm or overdose presentations to the Acute Mental Health Team for multidisciplinary safety and risk review.

Verbatim wording from the response

“Since the inquest we have amended our Standard Operating Procedure (SOP) in relation to patients who attend an Emergency Department, for a self-harm or overdose incident on 3 occasions within a four week period. These people will now be flagged within the Acute Mental Health Team (AMHT) and will be discussed within the MDT to review safety, risk and need and to agree whether any changes to their current care plan is required.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 29 January 2016

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

Collate and share information from agencies about people with frequent or escalating contact through High Intensity User Groups.

Verbatim wording from the response

“The wider information from other agencies that also have frequent and escalating contact with individuals will be collated and actioned through the High Intensity Usage Group and systems associated with this forum, as described below. There is two way sharing of information about this group of individuals between agencies in these forums.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 29 January 2016

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 High Intensity User Groups to North and West areas and connect them with Acute Mental Health Team care planning across the Trust.

Verbatim wording from the response

“These High Intensity User Groups are multi-agency forums and include representation from Police, Ambulance, Community Mental Health, Hampshire County Council Safeguarding and Emergency Department staff. The revised SOP also ensures that AMHT staff will engage with the High Intensity User groups in their local areas to support consistent care planning.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 2 · response
Published 29 January 2016

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

Formulate and obtain approval for standard arrangements ensuring patients seeking second opinions are not prematurely discharged and can access suitable appointments.

Verbatim wording from the response

“The Adult Mental Health Management Team have discussed this and an action has been assigned to the Clinical Service Directors in each area to formulate a standard plan to ensure that patients requesting second opinions have access to these, and are not prematurely discharged if they advise that they are unable to attend their appointment. There is agreement across all areas that a second opinion offer should be individually negotiated to the needs of the service user, and that if someone alerts us that they cannot attend the appointment then other arrangements will be made to facilitate the appointment either through a different venue or through the consultant travelling to another area. The standard process will depend on the geography of each area and consultants working arrangements.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 29 January 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.4

  1. 1

    Disseminate RCA learning and resulting actions across Adult Mental Health services through service-development and learning-network events.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 January 2016.
  2. 2

    Present the RCA learning and actions to the Hampshire-wide Crisis Concordat Steering Group and share the resulting minutes.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 January 2016.
  3. 3

    Monitor implementation of the disseminated actions through community and acute care forums and the Adult Mental Health Quality and Strategy Board.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 January 2016.
  4. 4

    Amend the disengagement policy to specify the process for patients disengaging from second-opinion arrangements.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 January 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

Disseminate RCA learning and resulting actions across Adult Mental Health services through service-development and learning-network events.

Verbatim wording from the response

“In order to ensure that learning from this case was shared across the whole of Adult Mental Health services the Root Cause Analysis (RCA) into the care and treatment that was provided to Miss Locke was discussed within the Adult Mental Health Service Development session on 3rd February 2016. This was attended by Clinical Service Directors, Area Managers, Heads of Nursing and Quality for all areas. In addition also present were the Associate Director, Clinical Director, Associate Director of Nursing and Italk Clinical Director. Communication took place in relation to the learning that came from the RCA and discussion followed regarding the Action Plan which received full commitment from them.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 2 · response
Published 29 January 2016

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

Present the RCA learning and actions to the Hampshire-wide Crisis Concordat Steering Group and share the resulting minutes.

Verbatim wording from the response

“Finally, given that we recognise that this is not just about sharing learning within Southern Health Foundation Trust on the 11th April 2016 ████████ will be presenting the Louise Locke RCA, learning and actions taken to date with the Hampshire Wide Crisis Concordat Steering Group in order that any actions which require a multi professional approach can be included in the action plan for 2016 /17 and once these minutes are available I will share these with you for your information and assurance.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 2 · response
Published 29 January 2016

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

Monitor implementation of the disseminated actions through community and acute care forums and the Adult Mental Health Quality and Strategy Board.

Verbatim wording from the response

“Further, an Adult Mental Health Services learning network event took place on 9 March 2016 at which 47 staff attended from across all Adult Mental Health services including inpatients, community and I talk - this included medical staff, team managers, team leaders and frontline clinicians. I understand that you were invited by ████████ Associate Director AMH to attend this Learning Network and have therefore seen the agenda. I have enclosed within this response the actions and learning taken from the day that has been shared across all teams and the implementation of these will be monitored through the appropriate community and acute care forums and the AMH Quality and Strategy Board in order that we can provide ongoing improvements and assurances around reducing the likelihood of a recurrence of a similar nature with other patients.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 2 · response
Published 29 January 2016

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

Amend the disengagement policy to specify the process for patients disengaging from second-opinion arrangements.

Verbatim wording from the response

“These plans will be brought back to the Clinical Director ████████ for sign off on the 21st April at the directors meeting. Risk assessments should take place prior to any discharge and this has been communicated through all learning events related to this RCA. The disengagement policy will be amended to reflect the process to follow disengagement from a second opinion.”

Source location

2016-0026-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 29 January 2016

Open published response
Back to top

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