PFD report

Timothy John Smedley · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 16 Nov 2017•Manchester North

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised3

  1. Difficulties in accessing appropriate and timely mental health services for patients with known alcohol addiction
  2. Lack of access to NHS records by out-of-hours services
    Part of recurring concern: Unreliable consolidation and access to patients’ cross-service clinical risk information
  3. Lack of awareness of the complexities of presentations involving known alcohol addiction
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.6

  1. Action

    Work towards interoperable digital care records across health and care services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
  2. Action

    Invest £247 million to implement liaison mental health services in emergency departments.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
  3. Action

    Implement comprehensive community-based mental health pathways of care by 2020.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.

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

  1. Position

    Local commissioners and providers are responsible for implementing improvements enabling people with co-occurring conditions to access appropriate care and support.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Difficulties in accessing appropriate and timely mental health services for patients with known alcohol addiction

Wider context from the report

“2. The difficulties that patients with known alcohol addiction face in accessing appropriate and timely mental health services, alongside an apparent lack of awareness surrounding the complexities their presentation. ”

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

Lack of access to NHS records by out-of-hours services

Wider context from the report

“1. The lack of (joint) access to NHS records by ‘out of hours’ services such as GPs, Urgent Care Centres etc. resulting in unsafe, fragmentation of care. ”

Is this part of a recurring concern?

Yes — Unreliable consolidation and access to patients’ cross-service clinical risk information.

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 awareness of the complexities of presentations involving known alcohol addiction

Wider context from the report

“2. The difficulties that patients with known alcohol addiction face in accessing appropriate and timely mental health services, alongside an apparent lack of awareness surrounding the complexities their presentation. ”

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

Work towards interoperable digital care records across health and care services.

Verbatim wording from the response

“We expect that challenges around the sharing of patient information will, in large part, be addressed by the move away from paper records to electronic systems for recording and sharing patient information. Digitisation provides an important opportunity to improve communication flow in the interests of patient safety, leading to improved outcomes and efficiency.”

Source location

2017-0398-Response-by-Department-of-Health
Page 2 · response
Published 15 February 2018

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

Invest £247 million to implement liaison mental health services in emergency departments.

Verbatim wording from the response

“In response to this, and through record investment, we are implementing the vision set out in the Five Year Forward View for Mental Health to transform mental health services. This includes investing £400 million to improve crisis care services in the community and £247 million to implement liaison mental health services in emergency departments so that people who present at acute hospitals with mental health problems will be seen by specially trained mental health professionals. Through the Five Year Forward View for Mental Health we are committed to implementing a comprehensive range of community-based mental health pathways of care by 2020.”

Source location

2017-0398-Response-by-Department-of-Health
Page 3 · response
Published 15 February 2018

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

Implement comprehensive community-based mental health pathways of care by 2020.

Verbatim wording from the response

“In response to this, and through record investment, we are implementing the vision set out in the Five Year Forward View for Mental Health to transform mental health services. This includes investing £400 million to improve crisis care services in the community and £247 million to implement liaison mental health services in emergency departments so that people who present at acute hospitals with mental health problems will be seen by specially trained mental health professionals. Through the Five Year Forward View for Mental Health we are committed to implementing a comprehensive range of community-based mental health pathways of care by 2020.”

Source location

2017-0398-Response-by-Department-of-Health
Page 3 · response
Published 15 February 2018

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

Expand Summary Care Record availability and use across more settings, including urgent and emergency care.

Verbatim wording from the response

“You may be aware of the introduction of the Summary Care Record which now covers more than 98 percent of the population. The Summary Care Record is being used successfully in many settings across the NHS such as A&E departments, hospital pharmacies, NHS 111, GP out-of-hours services and walk-in centres. Additionally, the Summary Care Record can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.”

Source location

2017-0398-Response-by-Department-of-Health
Page 2 · response
Published 15 February 2018

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 implementing Mental Health Crisis Care Concordat actions and developing and embedding local action plans.

Verbatim wording from the response

“We also remain committed to implementing the actions of the national Mental Health Crisis Care Concordat so that no one experiencing a mental health crisis is turned away. Every area has a local Crisis Care Concordat action plan in place and we continue to work with the signatories of the Concordat to ensure these local plans continue to develop and embed within local communities.”

Source location

2017-0398-Response-by-Department-of-Health
Page 3 · response
Published 15 February 2018

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

Invest £400 million to improve community crisis care services.

Verbatim wording from the response

“In response to this, and through record investment, we are implementing the vision set out in the Five Year Forward View for Mental Health to transform mental health services. This includes investing £400 million to improve crisis care services in the community and £247 million to implement liaison mental health services in emergency departments so that people who present at acute hospitals with mental health problems will be seen by specially trained mental health professionals. Through the Five Year Forward View for Mental Health we are committed to implementing a comprehensive range of community-based mental health pathways of care by 2020.”

Source location

2017-0398-Response-by-Department-of-Health
Page 3 · response
Published 15 February 2018

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

Local commissioners and providers are responsible for implementing improvements enabling people with co-occurring conditions to access appropriate care and support.

Verbatim wording from the response

“It is the responsibility of commissioners and providers to work together at a local level to implement the necessary improvements to ensure this vulnerable group of patients are able to access the high quality care and support to meet their needs. Commissioners are supported through a wide range of planning and assessment processes, payment incentive tools and clinical guidance to develop local solutions.”

Source location

2017-0398-Response-by-Department-of-Health
Page 5 · response
Published 15 February 2018

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