PFD report

Jason Ricardo White · Prevention of Future Deaths report

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Issued 19 Dec 2025•South Yorkshire (Eastern)

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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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

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Concerns raised3

  1. Lack of full assessment after abrupt medication cessation
    Part of recurring concern: Failure to reassess safety risks during significant mental-health medication changes
  2. Risk of relapse and serious mental-health deterioration following abrupt medication cessation
    Part of recurring concern: Failure to reassess safety risks during significant mental-health medication changes
  3. Failure to monitor patients after abrupt medication cessation
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

    Standardise formal logging, multidisciplinary review, risk-based monitoring decisions, named clinical ownership and contingency recording after antipsychotic medication changes across all relevant services.

    Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.

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 full assessment after abrupt medication cessation

Wider context from the report

“1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed. 2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health. 3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health. ”

Is this part of a recurring concern?

Yes — Failure to reassess safety risks during significant mental-health medication 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

Risk of relapse and serious mental-health deterioration following abrupt medication cessation

Wider context from the report

“1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed. 2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health. 3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health. ”

Is this part of a recurring concern?

Yes — Failure to reassess safety risks during significant mental-health medication 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 monitor patients after abrupt medication cessation

Wider context from the report

“1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed. 2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health. 3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health. ”

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

Standardise formal logging, multidisciplinary review, risk-based monitoring decisions, named clinical ownership and contingency recording after antipsychotic medication changes across all relevant services.

Verbatim wording from the response

“As a direct response to the learning from this case, we have strengthened our approach to monitoring service users following changes to antipsychotic medication. These improvements are already being implemented in practice, with full standardisation across all relevant services to be completed by 1 March 2026.”

Source location

2025-0638 - Response from Sheffield Health Partnership University NHS Foundation Trust
Page 1 · response
Published 23 December 2025

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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