PFD report

Zak Miles Joe Walter Paul Farmer · Prevention of Future Deaths report

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Issued 24 Sep 2020•Essex

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
2

Named on the report

Responses found
2

Of 2 recipients

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 raised3

  1. Lack of defined steps when a patient cannot be contacted
    Part of recurring concern: Failure to maintain follow-up of patients who disengage from care
  2. Lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team
    Part of recurring concern: Unreliable urgent mental health referral and assessment pathways
  3. Inadequacy of clinical guidelines for community mental health service users disengaging or non concordant with prescribed treatment plans
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.1

  1. Action

    Review and strengthen the Community Mental Health Service disengagement guideline to provide comprehensive, clear staff guidance.

    Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2020.

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 defined steps when a patient cannot be contacted

Wider context from the report

“1. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted. ”

Is this part of a recurring concern?

Yes — Failure to maintain follow-up of patients who disengage from care.

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 clarity about the meaning of “urgent” referrals to the Access and Assessment Team

Wider context from the report

“1. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted. ”

Is this part of a recurring concern?

Yes — Unreliable urgent mental health referral and assessment pathways.

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

Inadequacy of clinical guidelines for community mental health service users disengaging or non concordant with prescribed treatment plans

Wider context from the report

“2. The trust document Clinical Guidelines for Community Mental Health Service Users disengaging or non concordant with current prescribed treatment plans was found lacking and requires perfecting. ”

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

Review and strengthen the Community Mental Health Service disengagement guideline to provide comprehensive, clear staff guidance.

Verbatim wording from the response

“In response to the matter of concern regarding the EPUT Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment”

Source location

2020-0196-Response-from-EPUT_Redacted.pdf
Page 1 · response
Published 27 November 2020

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.8

  1. 1

    Provide GPs access to prisoners’ clinical notes through SystmOne via NHS Spine.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  2. 2

    Provide each released prisoner with a discharge summary covering care plan, medication, and diagnosis details, and retain it on SystmOne.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  3. 3

    Standardize prisoner transfers through s117 attendance, multidisciplinary planning, recorded information, and regular liaison with Brockfield House.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  4. 4

    Transmit confidential medical information securely by email when prisoners transfer from Brockfield House through court.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  5. 5

    Employ a social inclusion representative to arrange clinical and social support before prisoner discharge, with senior mental-health-team supervision.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  6. 6

    Maintain dual SystmOne and card-index patient records with weekly accuracy audits and release reporting capability.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  7. 7

    Advise prisoners without community GPs how to register and record that advice on SystmOne.

    Stated by CRG Medical ServicesStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  8. 8

    Maintain a separate Crisis Response Service to action all crisis referrals.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Existing meetings, multidisciplinary planning, records and secure information transfer sufficiently address post-discharge medication and care-planning information.

    Stated by CRG Medical ServicesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    Discharge summaries, clinical-record access, GP-registration advice and supervised social-inclusion arrangements sufficiently address release information requirements.

    Stated by CRG Medical ServicesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Provide GPs access to prisoners’ clinical notes through SystmOne via NHS Spine.

Verbatim wording from the response

“Regarding concern number 2; the process of discharge has changed significantly since CRG took over responsibility for healthcare provision at HMP Chelmsford in April 2019 and the ability now exists for GPs to access clinical notes which are stored and managed on SystmOne. This access is available through ‘NHS Spine’ which is a relatively new development which was unfortunately not available at the time of Mr Farmer’s discharge from prison.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 2 · response
Published 27 November 2020

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

Provide each released prisoner with a discharge summary covering care plan, medication, and diagnosis details, and retain it on SystmOne.

Verbatim wording from the response

“In the event that a prisoner does not already have a community-based GP, advice is given by healthcare staff to assist the prisoner with how to register with a community GP. This advice is recorded on SystmOne and is available for examination. A discharge summary (this would include the care plan, medication and diagnosis details) also now accompanies the prisoner on release from prison. Records of the discharge summary are kept on SystmOne and are available for examination. These records are also accessible by GPs through NHS Spine as described above.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 2 · response
Published 27 November 2020

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

Standardize prisoner transfers through s117 attendance, multidisciplinary planning, recorded information, and regular liaison with Brockfield House.

Verbatim wording from the response

“In respect of concern number 1 above, a member of the mental health team attends all MHA s117 meetings prior to a prisoner being discharged back to HMP Chelmsford. The information contained within the s117 meeting minutes will determine the pathway, care plan and medicines management for that person. This information is discussed at the weekly multi-disciplinary team (MDT) meeting hosted by the mental health team. Minutes of these meetings are recorded on SystmOne and can be examined if required.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Transmit confidential medical information securely by email when prisoners transfer from Brockfield House through court.

Verbatim wording from the response

“In the event that a prisoner is transferred from Brockfield House to HMP Chelmsford via court rather than being directly transferred, any relevant confidential medical information is ████████ Brockfield House to the healthcare team at HMP Chelmsford via secure email facility. This secure email facility has replaced the previous postal/fax system that was in place at the time of Mr Farmer’s transfer between the two institutions.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Employ a social inclusion representative to arrange clinical and social support before prisoner discharge, with senior mental-health-team supervision.

Verbatim wording from the response

“Additionally, CRG employ a social inclusion representative who has responsibility for ensuring that when a prisoner is discharged, arrangements are made on behalf of the prisoner so that the provision of clinical details and other social arrangements are in place prior to discharge from prison. A record of individual prisoners’ discharge arrangements is stored on SystmOne and is available for examination. The discharge process is monitored and supervised by a senior member of the mental health team.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 2 · response
Published 27 November 2020

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

Maintain dual SystmOne and card-index patient records with weekly accuracy audits and release reporting capability.

Verbatim wording from the response

“The mental health team now have a dual system (SystmOne and a card index system) both of which contain up to date records of current patients being seen by the unit. This provides a safeguard should SystmOne be offline for any length of time. This dual system is audited each week to ensure both are accurate and updated and the ability exists to run reports on the number of patients released from prison on a month by month basis.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Advise prisoners without community GPs how to register and record that advice on SystmOne.

Verbatim wording from the response

“In the event that a prisoner does not already have a community-based GP, advice is given by healthcare staff to assist the prisoner with how to register with a community GP. This advice is recorded on SystmOne and is available for examination. A discharge summary (this would include the care plan, medication and diagnosis details) also now accompanies the prisoner on release from prison. Records of the discharge summary are kept on SystmOne and are available for examination. These records are also accessible by GPs through NHS Spine as described above.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 2 · response
Published 27 November 2020

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

Maintain a separate Crisis Response Service to action all crisis referrals.

Verbatim wording from the response

“Since April 2020 the Trust has established a separate Crisis Response Service and all crisis referrals are now actioned by this team.”

Source location

2020-0196-Response-from-EPUT_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Existing meetings, multidisciplinary planning, records and secure information transfer sufficiently address post-discharge medication and care-planning information.

Verbatim wording from the response

“In respect of concern number 1 above, a member of the mental health team attends all MHA s117 meetings prior to a prisoner being discharged back to HMP Chelmsford. The information contained within the s117 meeting minutes will determine the pathway, care plan and medicines management for that person. This information is discussed at the weekly multi-disciplinary team (MDT) meeting hosted by the mental health team. Minutes of these meetings are recorded on SystmOne and can be examined if required.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 1 · response
Published 27 November 2020

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 summaries, clinical-record access, GP-registration advice and supervised social-inclusion arrangements sufficiently address release information requirements.

Verbatim wording from the response

“Regarding concern number 2; the process of discharge has changed significantly since CRG took over responsibility for healthcare provision at HMP Chelmsford in April 2019 and the ability now exists for GPs to access clinical notes which are stored and managed on SystmOne. This access is available through ‘NHS Spine’ which is a relatively new development which was unfortunately not available at the time of Mr Farmer’s discharge from prison.”

Source location

2020-0196-Response-from-CRG-Medical_Redacted.pdf
Page 2 · response
Published 27 November 2020

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