PFD report

Ann Pickering · Prevention of Future Deaths report

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Issued 4 Jul 2022•South Yorkshire (Western)

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
2

Named on the report

Responses found
2

Of 2 recipients

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.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Delays in inserting required NG tubes
    Part of recurring concern: Failure to provide timely clinical carePart of recurring concern: Unsafe management of Ryles and nasogastric tubes
  2. Lack of clear procedures for transferring patients under a section
    Part of recurring concern: Unreliable healthcare patient transfer processes
  3. Lack of clear procedures for documentation and resources accompanying transferred patients
    Part of recurring concern: Unreliable healthcare patient transfer processes
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.5

  1. Action

    Review the existing nutrition policy and agree nutritional-support and nasogastric-tube insertion requirements for detained patients, including restraint situations.

    Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  2. Action

    Develop a co-produced operational protocol defining safe transfer, referral, escalation, documentation, resources, multidisciplinary review and responsible clinicians.

    Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  3. Action

    Amend inter-Trust agreements and relevant policies to clarify responsibilities for transferring detained patients.

    Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.

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

Delays in inserting required NG tubes

Wider context from the report

“During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinical care; Unsafe management of Ryles and nasogastric tubes.

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 clear procedures for transferring patients under a section

Wider context from the report

“During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 clear procedures for documentation and resources accompanying transferred patients

Wider context from the report

“During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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

Delays in accepting transfers of patients under a section

Wider context from the report

“During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

Is this part of a recurring concern?

Yes — Unreliable Mental Health Act detention arrangements; Unreliable healthcare patient transfer 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

Review the existing nutrition policy and agree nutritional-support and nasogastric-tube insertion requirements for detained patients, including restraint situations.

Verbatim wording from the response

“In addition to collaborative working between SWYPFT and BHNFT, a review of BHNFT’s existing nutrition policy and agreement on meeting a patient’s nutritional requirements particularly for detained patients, including where there is a need for restraint will be undertaken jointly.”

Source location

Response from NHS South West Yorkshire Partnership
Page 2 · response
Published 27 September 2022

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

Develop a co-produced operational protocol defining safe transfer, referral, escalation, documentation, resources, multidisciplinary review and responsible clinicians.

Verbatim wording from the response

“BHNFT and SWYPFT are improving and clarifying the process which includes a protocol that details operational delivery of a safe and effective pathway, which will include:”

Source location

Response from NHS South West Yorkshire Partnership
Page 1 · response
Published 27 September 2022

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

Amend inter-Trust agreements and relevant policies to clarify responsibilities for transferring detained patients.

Verbatim wording from the response

“An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities – for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1).”

Source location

Response from NHS South West Yorkshire Partnership
Page 2 · response
Published 27 September 2022

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

Distribute interim transfer guidance to staff of both Trusts.

Verbatim wording from the response

“An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities – for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1).”

Source location

Response from NHS South West Yorkshire Partnership
Page 2 · response
Published 27 September 2022

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

Put in place a standard operating procedure with timescales for timely nutritional support and clear cross-Trust responsibilities.

Verbatim wording from the response

“Nutritional support will be provided in a timely manner by staff from the respective Trusts being clear about their roles and responsibilities in their own organisations, and collectively so that delays do not arise. A standard operating procedure to clarify this along with clear timescales will be in place by 30 November 2022 (EXHIBIT 1).”

Source location

Response from NHS South West Yorkshire Partnership
Page 2 · response
Published 27 September 2022

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.1

  1. 1

    Identify lead clinical staff responsible for each aspect of detained patients’ management after transfer.

    Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 27 September 2022.

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

Identify lead clinical staff responsible for each aspect of detained patients’ management after transfer.

Verbatim wording from the response

“(d) Identification of lead clinical staff, including clear plans for which clinician is responsible for each aspect of a patient’s management, where they are under a section and transferred to BHNFT (S17 Leave).”

Source location

Response from NHS South West Yorkshire Partnership
Page 3 · response
Published 27 September 2022

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