PFD report

Kevin Anthony Ince · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 18 Nov 2024•Lancashire and Blackburn with Darwen

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised4

  1. Failure to take sufficient steps to persuade patients detained under the Mental Health Act who refuse necessary and appropriate medical treatment
    Part of recurring concern: Unsafe management of refusal of necessary care or protective action
  2. Insufficient action in response to routine food refusal by patients detained under the Mental Health Act 1983
    Part of recurring concern: Unsafe management of refusal of necessary care or protective action
  3. Failure to sufficiently consider using section 63 of the Mental Health Act 1983 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment
    Part of recurring concern: Unsafe management of refusal of necessary care or protective action
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

    Operate and review a database weekly to monitor food and fluid intake, with documented actions when patients refuse adequate nutrition.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 26 November 2024.
  2. Action

    Review the poor-diet-and-fluid-intake flowchart to include capacity, best interests, family involvement and section 63 considerations.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 26 November 2024.
  3. Action

    Deliver a staff briefing on good nutrition and fluid intake at Priory Hospital Kemple View.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 November 2024.

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 take sufficient steps to persuade patients detained under the Mental Health Act who refuse necessary and appropriate medical treatment

Wider context from the report

“(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

Is this part of a recurring concern?

Yes — Unsafe management of refusal of necessary care or protective action.

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

Insufficient action in response to routine food refusal by patients detained under the Mental Health Act 1983

Wider context from the report

“(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

Is this part of a recurring concern?

Yes — Unsafe management of refusal of necessary care or protective action.

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 sufficiently consider using section 63 of the Mental Health Act 1983 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment

Wider context from the report

“(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

Is this part of a recurring concern?

Yes — Unsafe management of refusal of necessary care or protective action.

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 sufficiently consider powers under the Mental Capacity Act 2005 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment

Wider context from the report

“(1) The inquest heard clear evidence of lower refusals of necessary and appropriate medical treatment by patient detained under the Mental Health Act 1983, over several years with insufficient consideration of steps that were then appropriate including a lack of steps to persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983 (2) Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely declined food over a prolonged period. ”

Is this part of a recurring concern?

Yes — Failure to reliably apply Mental Capacity Act principles in care decisions; Unsafe management of refusal of necessary care or protective action.

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

Operate and review a database weekly to monitor food and fluid intake, with documented actions when patients refuse adequate nutrition.

Verbatim wording from the response

“A database has also been created at Kemple View to capture data about patients who are monitored using food and fluid intake charts: this will facilitate a more thorough review as to whether adequate nutrition is being accepted by the patient. This database is now reviewed weekly during an extended hospital handover meeting, with actions documented in accordance with the flowchart where a nutritional diet is refused.”

Source location

Response from The Priory
Page 2 · response
Published 26 November 2024

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 poor-diet-and-fluid-intake flowchart to include capacity, best interests, family involvement and section 63 considerations.

Verbatim wording from the response

“Following Mr Ince’s death, a ‘Management of Poor Diet and Fluid Intake’ flowchart was also introduced at Kemple View. I understand this was also explained by the Hospital Director during the inquest. This flowchart shows the process to follow when a patient has inadequate diet and fluid intake, to include escalation to the Responsible Clinician for discussion and referral to the Dietician for advice. The patient’s capacity to refuse an adequate nutritional diet is to be assessed and where the patient is deemed to be without capacity, a best interest meeting is to be arranged. All decision making is to be documented.”

Source location

Response from The Priory
Page 2 · response
Published 26 November 2024

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 a staff briefing on good nutrition and fluid intake at Priory Hospital Kemple View.

Verbatim wording from the response

“A Priory dietician is scheduled to complete a briefing to Priory Hospital Kemple View staff in January 2025 on the topic of good nutrition and fluid intake.”

Source location

Response from The Priory
Page 2 · response
Published 26 November 2024

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.5

  1. 1

    Operate and review a RAG-rated database weekly to record declined physical-health monitoring and document actions for non-compliance.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 26 November 2024.
  2. 2

    Build a CareNotes dashboard to monitor electronic physical-health observation checks and refusals.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 November 2024.
  3. 3

    Revise the physical-health-monitoring flowchart to address capacity, best interests, family involvement and section 63 considerations when patients decline checks.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 26 November 2024.
  4. 4

    Add the revised physical-health-monitoring flowchart to Priory policy and cross-reference it in relevant Mental Health Act and Mental Capacity Act policies for use across services.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 November 2024.
  5. 5

    Incorporate electronic monitoring of physical-health observations and refusals into CareNotes.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 November 2024.

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

Operate and review a RAG-rated database weekly to record declined physical-health monitoring and document actions for non-compliance.

Verbatim wording from the response

“A database has also been created at Kemple View to improve the recording of data about patients who have refused physical health monitoring using a clear RAG (Red, Amber, Green) rating system. This database is now reviewed weekly during the enhanced handover meeting, with actions documented where non-compliance is observed in accordance with the flowchart.”

Source location

Response from The Priory
Page 2 · response
Published 26 November 2024

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

Build a CareNotes dashboard to monitor electronic physical-health observation checks and refusals.

Verbatim wording from the response

“Discussions have also been ongoing with Priory’s IT department to explore how the above monitoring could be captured within CareNotes (Priory’s electronic patient records system). Electronic monitoring of physical health observation checks and refusals by patients will be incorporated within CareNotes in January 2025 and a dashboard to enable monitoring of this will be built into CareNotes from February 2025.”

Source location

Response from The Priory
Page 2 · response
Published 26 November 2024

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

Revise the physical-health-monitoring flowchart to address capacity, best interests, family involvement and section 63 considerations when patients decline checks.

Verbatim wording from the response

“Following Mr Ince’s death, a ‘Management of Declined Physical Health Monitoring’ flowchart was introduced at Kemple View. I understand the mechanics of this were explained by the Hospital Director during the inquest. This flowchart sets out the process to follow when a patient declines physical health checks, to include escalation to the Responsible Clinician and Primary Nurse for discussion at the next multi-disciplinary team (MDT) meeting. The patient’s capacity to decline physical health checks is to be assessed and where the patient is deemed to be without capacity, a best interest meeting is to be arranged. All decision making is to be documented.”

Source location

Response from The Priory
Page 1 · response
Published 26 November 2024

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

Add the revised physical-health-monitoring flowchart to Priory policy and cross-reference it in relevant Mental Health Act and Mental Capacity Act policies for use across services.

Verbatim wording from the response

“The revised flowchart was presented at the Physical Healthcare Committee meeting, which is chaired by Priory’s Chief Medical Officer on 10th January 2025 for discussion and will be added to Priory policy “H100 Monitoring Physical Health of Inpatients” and cross referenced within relevant Mental Health Act or Mental Capacity Act policies, for use across all Priory Healthcare services. It is proposed that consideration be given to implementing a focused e-learning training module to support colleagues to understand the interface between the Mental Health”

Source location

Response from The Priory
Page 1 · response
Published 26 November 2024

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

Incorporate electronic monitoring of physical-health observations and refusals into CareNotes.

Verbatim wording from the response

“Discussions have also been ongoing with Priory’s IT department to explore how the above monitoring could be captured within CareNotes (Priory’s electronic patient records system). Electronic monitoring of physical health observation checks and refusals by patients will be incorporated within CareNotes in January 2025 and a dashboard to enable monitoring of this will be built into CareNotes from February 2025.”

Source location

Response from The Priory
Page 2 · response
Published 26 November 2024

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