PFD report

Christopher Henrik LARSEN · Prevention of Future Deaths report

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Issued 13 Jun 2024•Rutland and North Leicestershire

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
9

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
14

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 raised9

  1. Failure to embed serious incident learning and changes in frontline practice
    Part of recurring concern: Unsafe implementation and oversight of service changes
  2. Failure to document MDT meeting decision making and risk downgrading rationale
    Part of recurring concern: Failure to reliably document the rationale for consequential decisionsPart of recurring concern: Unreliable recording of safety-critical mental health information
  3. Failure to provide a requested medic review
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.11

  1. Action

    Run a rapid improvement programme using quality-improvement methodology to identify improvements to the serious-incident investigation and reporting process.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
  2. Action

    Include a senior nurse clinician, medical colleagues and crisis-service members in MDT meetings to oversee and support the process.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.
  3. Action

    Implement the revised MDT template and pre-MDT referral process to clarify referrals and capture clinical information, decisions, actions and owners.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.

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

  1. Position

    Red-flag risk factors alone do not establish likelihood of self-harm or suicide; risk decisions should be based on clinical formulation.

    Stated by Leicestershire Partnership NHS 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 embed serious incident learning and changes in frontline practice

Wider context from the report

“4. The Serious Investigation and Reporting Process at LPT I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust. The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan. There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation. Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff. I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients, further, I have concerns about the ability of the Trust to embed changes and learning. This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust. ”

Is this part of a recurring concern?

Yes — Unsafe implementation and oversight of service changes.

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 MDT meeting decision making and risk downgrading rationale

Wider context from the report

“1. Multi-Disciplinary Team (“MDT”) Meetings I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen. It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients. The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information. There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.” At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting. ”

Is this part of a recurring concern?

Yes — Failure to reliably document the rationale for consequential decisions; Unreliable recording of safety-critical mental health 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

Failure to provide a requested medic review

Wider context from the report

“1. Multi-Disciplinary Team (“MDT”) Meetings I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen. It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients. The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information. There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.” At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting. ”

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 link identified serious incident failings to action-plan work

Wider context from the report

“4. The Serious Investigation and Reporting Process at LPT I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust. The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan. There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation. Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff. I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients, further, I have concerns about the ability of the Trust to embed changes and learning. This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety 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 planned post-discharge support

Wider context from the report

“3. Discharge Mr Larsen was discharged from the care of LPT on 3 December 2022, there was no planned support for Mr Larsen post-discharge other than some counselling which was due to start three weeks later. The Trust’s SI report states that it is “unclear why it was felt the risks had subsided by the time of discharge on 3.12.2022” and that Mr Larsen had the “presence of ample markers for high risk of completed suicide” yet he was discharged back to the care of his GP and into a lacuna of care with no pre-arranged support other than counselling which would not commence for three weeks. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; 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 use accurate medical record information in MDT decision making

Wider context from the report

“1. Multi-Disciplinary Team (“MDT”) Meetings I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen. It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients. The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information. There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.” At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting. ”

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 revisit working diagnoses and explore potential severe depressive disorder

Wider context from the report

“1. Multi-Disciplinary Team (“MDT”) Meetings I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and their functionality. Mr Larsen was discussed at three meetings, at two of the three meetings none of the attendees had met Mr Larsen. It was at an MDT meeting where Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was downgraded to low risk by the MDT meeting because the MDT meeting documentation does not contain that information. The issue of poor documentation relating to MDT meetings and their decision making is something which could have ramifications across the whole Trust and also for other bodies who come together to provide care for patients. The MDT meeting either misread or misunderstood Mr Larsen’s medical records. The notes document that Mr Larsen explained that he had previously placed a bag over his head and that this remained the way he would end his life, he advised that he could not give assurances that he would not try to do this again. The MDT documentation however states that Mr Larsen “wrapped plastic bag over his face but self-rescued, does not want to do it again”. This is incorrect. The MDT meeting therefore proceeded, and made decisions based upon, incorrect information. There were several requests made to MDT meetings for Mr Larsen to have a medic review, the MDT deemed this to be unnecessary but there is no documentation explaining the rationale of those decision. The Trust SI report states that “it is unfortunate that he was not reviewed by a medic.” At the second MDT meeting on 17ᵗʰ November the working diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis was not revisited at the third MDT on 22ⁿᵈ November. The Trust’s SI report states that by 17ᵗʰ November there was evidence of a severe depressive disorder, this potential diagnosis was not identified or explored by the MDT meeting. ”

Is this part of a recurring concern?

Yes — Failure to consider or reconsider serious alternative diagnoses.

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 robustly consider red-flag risk factors in risk assessments

Wider context from the report

“2. Risk assessments At his initial triage (undertaken by the Central Access Point) Mr Larsen was deemed to be high risk. At a later MDT meeting Mr Larsen was deemed to be low risk. It is not possible to explore the rationale behind the downgrading of Mr Larsen’s risk to low because there is no documentation about the decision making. The Trust’s SI report identified the fact that several “red flag” risk factors which applied to Mr Larsen were not “robustly considered” when assessing Mr Larsen’s risk. The Trust’s SI report states that it was “unclear why it was felt the risks had subsided by the time of discharge on 3.12.2022”. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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 of serious incident investigations to robustly and critically examine all relevant care issues

Wider context from the report

“4. The Serious Investigation and Reporting Process at LPT I remain concerned about inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust. The Serious Incident Investigation into Mr Larsen’s death did uncover and accepted some failings in relation to the care provided to Mr Larsen. However, it failed to uncover all the matters arising at inquest and, some of the matters that it did uncover do not have correlating items of work listed in the action plan. There was no exploration of the MDT meeting’s functionality or documentation as part of the SI investigation. Further, I have concerns about the implementation and embedding of the lessons learned which are identified by the SI Report. In this case the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff. I am therefore concerned that the SI process at LPT does not support a robust and critical analysis and investigation of the care provided to patients, further, I have concerns about the ability of the Trust to embed changes and learning. This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole Trust. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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

Run a rapid improvement programme using quality-improvement methodology to identify improvements to the serious-incident investigation and reporting process.

Verbatim wording from the response

“We take learning form serious incidents very seriously and have taken on board feedback provided relating to the processes within the Trust. All serious incident reports are reviewed by the Medical Director and Chief Nurse to ensure that they provide a critical analysis and investigation of the care provided to patients. We also recognise that the transition to the new National Patient Safety Incident Response Framework (PSIRF) has taken time to embed. Feedback from the new PSIRF process has been positive from families and clinicians. In order to make the process more robust a rapid improvement programme is underway to utilise quality improvement methodology to identify any improvements which can be made to the process.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 5 · response
Published 14 June 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

Include a senior nurse clinician, medical colleagues and crisis-service members in MDT meetings to oversee and support the process.

Verbatim wording from the response

“The MDT meeting attendance has also been reviewed to include a senior nurse clinician to oversee the process along with medical colleagues and other members of the crisis service. The MDT meeting will utilise the information within the pre-MDT template and the most recent Core assessment, Risk assessment and the contemporaneous clinical notes to inform the clinical discussions. The discussions within the MDT will be captured in real-time in the MDT template and the outcomes, decisions and actions agreed and documented; the MDT template forms part of the patient notes and will be immediately available.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 2 · response
Published 14 June 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

Implement the revised MDT template and pre-MDT referral process to clarify referrals and capture clinical information, decisions, actions and owners.

Verbatim wording from the response

“As part of immediate learning and action taken relating to the concerns you have raised directly about the MDT meeting and documentation, we have reviewed and made substantial changes to the MDT template to be used for MDT meetings [Appendix 1]. In addition, after engagement with clinical staff and extended reflection on the death of Christopher Larsen, we have also implemented a process to provide further clarity on the reason for referral into the MDT meeting via pre-MDT sections to be completed on the MDT template. This template will be completed by the clinician who had the last clinical contact with the patient prior to the MDT meeting. The information captured in this template and the reason for the referral into the MDT meeting will be discussed with the patient at this clinical contact and will support the information captured within the patient’s notes and risk assessment.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 2 · response
Published 14 June 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

Present the risk-assessment review outcomes to the Urgent Care Quality and Safety Meeting to inform required changes.

Verbatim wording from the response

“As the assessment of risk is a key component to the effectiveness of the clinicians working within the Crisis team, the Trust is completing a review of our competency framework and the audit tool to support the monitoring of robust documentation of risk assessment/formulation. This review was completed on 02 August 2024. The outcomes of the review will be presented to the Urgent Care Quality and Safety Meeting on the 22 August 2024 to inform any required changes.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 4 · response
Published 14 June 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 Crisis Resolution Home Treatment Team SOP to clarify MDT processes and when medical review should be considered or offered, and disseminate it with staff confirmation of understanding.

Verbatim wording from the response

“The Crisis Resolution Home Treatment Team Standard Operating Procedure (SOP) [Appendix 2] has also been reviewed and amended to clearly explain all these processes for our staff and includes specific guidance on how to identify when a medical review should be considered/offered as this is not required for all patients. The revised SOP was agreed on 24 July 2024 and was circulated to all staff via email on 25 July 2024; it was also shared in team meetings which take place weekly. Staff have been required to sign a confirmation that they have read and understand the SOP and the new process.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 3 · response
Published 14 June 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

Conduct monthly audits of MDT processes and documentation, share feedback with staff, review outcomes through quality governance, and undertake additional six-month senior scrutiny.

Verbatim wording from the response

“To provide assurance to the Directorate senior clinical team, audits will be undertaken monthly to ensure the processes and documents are being completed fully and to the standards expected. Feedback from the audits will be shared with the staff involved via their weekly meeting to ensure they are aware of areas requiring improvement. The outcomes of the audit will be reviewed within the Directorate Quality and Safety Governance meeting, with evidence of learning shared; this will be monitored monthly. In addition, the Chief Nurse and Medical Director will review the audits, sample of decisions and outcomes of the new process in six months to provide additional assurance and scrutiny.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 2 · response
Published 14 June 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

Complete the review of the clinical risk-assessment competency framework and audit tool to strengthen monitoring of risk-assessment and formulation documentation.

Verbatim wording from the response

“As the assessment of risk is a key component to the effectiveness of the clinicians working within the Crisis team, the Trust is completing a review of our competency framework and the audit tool to support the monitoring of robust documentation of risk assessment/formulation. This review was completed on 02 August 2024. The outcomes of the review will be presented to the Urgent Care Quality and Safety Meeting on the 22 August 2024 to inform any required changes.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 4 · response
Published 14 June 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 causal factors and deliver additional training to the team on reading clinical records before Safe and Well calls and clinical decisions.

Verbatim wording from the response

“We understand and recognise that this has occurred previously and as part of our ongoing learning we are reviewing all causal factors whilst reminding clinicians of the importance of reviewing medical records before taking any clinical decisions. Additional training has been delivered to this team regarding professional responsibility for reading a clinical record before making calls and taking clinical decisions.”

Source location

Response from Leicestershire Partnership NHS (1)
Page 2 · response
Published 14 June 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

Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.

Verbatim wording from the response

“As a learning point from the feedback provided, we are reviewing the layout of the safe and well template to ensure that this is in a format which makes this as easy as possible for call takers to review the information and assess risk and capture information from the call. The new template will be co-produced with staff and will be signed off by the Information Management and Technology (IM&T) Clinical Safety and Improvement Group.”

Source location

Response from Leicestershire Partnership NHS (1)
Page 2 · response
Published 14 June 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

Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.

Verbatim wording from the response

“Training and team meetings are important vehicles for us in reminding people of the importance of this, and we are also formalising this by updating the Central Access Point Standard Operating Procedure (SOP) to be explicit that it is the clinician’s responsibility to manage their own allocated work for the shift, look through the referrals having considered the patient record and prioritise the triage calls on risk, urgency and patient availability.”

Source location

Response from Leicestershire Partnership NHS (1)
Page 2 · response
Published 14 June 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 additional training and reflection sessions for the nurse and her line manager regarding the case context.

Verbatim wording from the response

“Regular training, clinical supervision and reflection sessions take place routinely for clinical staff, however following this feedback, additional training and reflection sessions were undertaken with the nurse, and the line manager of the nurse to fully understand the context in this case. A full investigation into the nurses’ practice is underway internally; this will include consideration of the appropriateness of an NMC referral in line with Trust processes. In the meantime, the nurse is restricted from undertaking any nursing shifts within community services within the Trust or as a practicing lone qualified member of staff in an inpatient setting until the investigation concludes.”

Source location

Response from Leicestershire Partnership NHS (1)
Page 2 · response
Published 14 June 2024

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

Red-flag risk factors alone do not establish likelihood of self-harm or suicide; risk decisions should be based on clinical formulation.

Verbatim wording from the response

“The risk assessment undertaken by the clinician presenting a case to the MDT, forms part of the information considered by the MDT in accordance with NICE [NG225] guidelines which state that decisions about care should not be made based on risk assessment tools and should be based on clinical formulation. Additionally, they state that the aforementioned 'red flag' risk factors alone do not indicate the likelihood of self-harm or suicide amongst the patients under crisis (who by the nature of their presentation, would all be deemed at a higher level of risk than those in the general population). The MDT considers the clinicians assessment of risk at the time of assessment. When the outcome of the MDT is shared with the patient, it offers a further opportunity for the clinician to assess whether the risk presentation has changed from the previous assessment.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 3 · response
Published 14 June 2024

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

Discharge to primary care is considered appropriate for many patients when supported by a collaboratively formulated crisis and contingency plan with 24-hour access.

Verbatim wording from the response

“The Crisis Resolution Home Treatment Team is a short-term, needs-based intervention service whose primary role is to mitigate the requirement for inpatient admission to an acute mental health hospital setting. Patients are referred into the service for intensive home treatment from a variety of different settings, including both primary and secondary care. For a substantial number of patients who have received care from the team, a referral into secondary care is not clinically appropriate or indicated. Many patients are subsequently discharged back to primary care following the formulation of a clear crisis and contingency plan which is formulated in collaboration with the patient (and carers where applicable).”

Source location

Response from Leicestershire Partnership NHS (2)
Page 4 · response
Published 14 June 2024

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

Medical review is not required for every patient; the revised SOP provides guidance on when medical review should be considered or offered.

Verbatim wording from the response

“The Crisis Resolution Home Treatment Team Standard Operating Procedure (SOP) [Appendix 2] has also been reviewed and amended to clearly explain all these processes for our staff and includes specific guidance on how to identify when a medical review should be considered/offered as this is not required for all patients. The revised SOP was agreed on 24 July 2024 and was circulated to all staff via email on 25 July 2024; it was also shared in team meetings which take place weekly. Staff have been required to sign a confirmation that they have read and understand the SOP and the new process.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 3 · response
Published 14 June 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.3

  1. 1

    Conduct quality summits focused on safety, leadership and governance within the crisis pathway to support accountability and learning.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
  2. 2

    Investigate the nurse’s practice and consider whether an NMC referral is appropriate under Trust processes.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
  3. 3

    Restrict the nurse from community nursing shifts and lone qualified inpatient duties until the investigation concludes.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 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

Conduct quality summits focused on safety, leadership and governance within the crisis pathway to support accountability and learning.

Verbatim wording from the response

“In addition, the Director of Nursing and the Medical Director have initiated quality summits that have focussed on safety, leadership, and governance within the crisis pathway. The summits have been a collaborative space involving leaders and staff within the service to ensure accountability and learning.”

Source location

Response from Leicestershire Partnership NHS (2)
Page 5 · response
Published 14 June 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

Investigate the nurse’s practice and consider whether an NMC referral is appropriate under Trust processes.

Verbatim wording from the response

“Regular training, clinical supervision and reflection sessions take place routinely for clinical staff, however following this feedback, additional training and reflection sessions were undertaken with the nurse, and the line manager of the nurse to fully understand the context in this case. A full investigation into the nurses’ practice is underway internally; this will include consideration of the appropriateness of an NMC referral in line with Trust processes. In the meantime, the nurse is restricted from undertaking any nursing shifts within community services within the Trust or as a practicing lone qualified member of staff in an inpatient setting until the investigation concludes.”

Source location

Response from Leicestershire Partnership NHS (1)
Page 2 · response
Published 14 June 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

Restrict the nurse from community nursing shifts and lone qualified inpatient duties until the investigation concludes.

Verbatim wording from the response

“Regular training, clinical supervision and reflection sessions take place routinely for clinical staff, however following this feedback, additional training and reflection sessions were undertaken with the nurse, and the line manager of the nurse to fully understand the context in this case. A full investigation into the nurses’ practice is underway internally; this will include consideration of the appropriateness of an NMC referral in line with Trust processes. In the meantime, the nurse is restricted from undertaking any nursing shifts within community services within the Trust or as a practicing lone qualified member of staff in an inpatient setting until the investigation concludes.”

Source location

Response from Leicestershire Partnership NHS (1)
Page 2 · response
Published 14 June 2024

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