PFD report

Ethel Mitchell ROBERTSON · Prevention of Future Deaths report

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Issued 17 Nov 2025•Hampshire, Portsmouth and Southampton

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

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

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Concerns raised1

  1. Failure to routinely inform OPMH of patients’ emergency department admissions and discharges
    Part of recurring concern: Failure to reliably notify specialist teams of hospital admissions and discharges
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Checking every Emergency Department patient for undisclosed mental illness is impractical and disproportionate because of workload, limited clinical indicators and privacy objections.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 routinely inform OPMH of patients’ emergency department admissions and discharges

Wider context from the report

“An Area Matron at the Older People’s Mental Health Service [OPMH] gave evidence that the service is not routinely informed when one of their patients is admitted to or discharged from ED. If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital. However, if the presentation is for something not related to mental health, the OPMH will not be notified as clinicians within the ED do not have access to the computer systems operated by service providers in the community. I am concerned that OPMH will not know if one of their patients has had a physical health crisis which could precipitate a decline in their mental health or has presented with something that those not familiar with the patient might fail to appreciate is linked to their mental health. I am concerned that this will have serious implications for patient safety and could delay appropriate follow-up, risk management and decision-making. It also places an added pressure on those in primary care to have systems in place to alert the community teams when they receive discharge documentation from ED. ”

Is this part of a recurring concern?

Yes — Failure to reliably notify specialist teams of hospital admissions and discharges.

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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

Checking every Emergency Department patient for undisclosed mental illness is impractical and disproportionate because of workload, limited clinical indicators and privacy objections.

Verbatim wording from the response

“However, to check every patient attending the Emergency Departments for physical health conditions as to whether or not they also have a mental illness is not practical. Some people with mental illness also have objections to their mental health records being shared more widely. Even with connected computer systems, the additional workload of checking every patient to establish whether they have mental health issues is disproportionate to the small number of cases where the mental health conditions are not evident to the clinicians in the Emergency Department.”

Source location

Response from Southern Health Foundation Trust
Page 1 · response
Published 19 November 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