PFD report

Mylon Sheppard · Prevention of Future Deaths report

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Issued 17 Jan 2019•Warwickshire

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised5

  1. Failure to maintain a system clearly identifying GP and geographical boundaries for local mental health services
    Part of recurring concern: Unreliable mental health referral pathways
  2. Failure to include willing family members in care planning
  3. Failure to effectively manage waiting lists
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 maintain a system clearly identifying GP and geographical boundaries for local mental health services

Wider context from the report

“(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams.. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral 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

Failure to include willing family members in care planning

Wider context from the report

“(4) Failure to ensure that family members are included in care planning (where the patient is happy for that to happen). ”

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 effectively manage waiting lists

Wider context from the report

“(2) Failure to effectively manage waiting lists. ”

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 maintain a clear Day Hospital process for patient non-attendance

Wider context from the report

“(3) Failure to have a clear process at the Day Hospital in respect of non attendance of patients. ”

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 of effective oversight of duty workers' decisions

Wider context from the report

“(1) Failure of any effective oversight of decisions made by duty workers. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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