PFD report

Rodney John DIXON · Prevention of Future Deaths report

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Issued 21 Jun 2021•East Sussex

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

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. Sub-optimal training for patient risk management
  2. Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessment
  3. Sub-optimal training for Mental Health Act assessments
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.4

  1. Action

    Review AMHP training and documentation relating to Mental Health Act assessments.

    Stated by East Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
  2. Action

    Introduce dynamic risk assessment requirements, supervision safeguards, and access to current risk and clinical information through updated assessment forms and internal publication.

    Stated by East Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
  3. Action

    Arrange annual risk-management training for existing Approved Mental Health Practitioners with Brighton University.

    Stated by East Sussex County CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Recruitment and training of doctors and other medical staff is the responsibility of Sussex Partnership Foundation Trust, not the Council.

    Stated by East Sussex County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Sub-optimal training for patient risk management

Wider context from the report

“Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”

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

Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments

Wider context from the report

“Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment.

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

Sub-optimal training for Mental Health Act assessments

Wider context from the report

“Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”

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

Sub-optimal training for Mental Health Act assessors

Wider context from the report

“Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”

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 AMHP training and documentation relating to Mental Health Act assessments.

Verbatim wording from the response

“The Council has reviewed its’ training and documentation in respect of AMHPs”

Source location

Response from East Sussex County Council
Page 2 · response
Published 28 June 2021

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

Introduce dynamic risk assessment requirements, supervision safeguards, and access to current risk and clinical information through updated assessment forms and internal publication.

Verbatim wording from the response

“(1) Leon Gooding (Head of Adult Social Care) hosted a meeting with all the Council’s Approved Mental Health Practitioners (AMHPs) to discuss the issues arising from this case. During the meeting, It was agreed that the client in cases similar to that of Mr. Dixon should not be left unsupervised unless assessed to be of low risk. The Council’s Mental Health Act referral and Risk Assessment Forms have been updated. They include a new section entitled “dynamic risk assessment”.”

Source location

Response from East Sussex County Council
Page 2 · response
Published 28 June 2021

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

Arrange annual risk-management training for existing Approved Mental Health Practitioners with Brighton University.

Verbatim wording from the response

“(2) Yearly risk management training with Brighton University for existing AMHP’s has been arranged. This is part of the annual training that AMHPs undergo anyway but it will now include specific training on risk management.”

Source location

Response from East Sussex County Council
Page 2 · response
Published 28 June 2021

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

Identify difficulties in established processes for accessing and sharing relevant patient information with MHA Assessors.

Verbatim wording from the response

“The Crisis Resolution Home Treatment Team are the Trust team that are available to support the MHA Assessors with access to relevant patient information and are available 24 hrs a day. However, I recognise your concerns and, therefore, have asked the Deputy Chief Nurse, when she discusses matters with ESCC, to identify if there are any difficulties with these established access processes that need to be addressed.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 28 June 2021

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

Recruitment and training of doctors and other medical staff is the responsibility of Sussex Partnership Foundation Trust, not the Council.

Verbatim wording from the response

“As a local authority, the Council is responsible for the recruitment, training, warranting and management of Approved Mental Health Practitioners (AMHPs). The Council has no input into the recruitment or training of Doctors and other medical staff who practise in this area. That is the responsibility of the Sussex Partnership Foundation Trust (SPFT) who have also been issued with a Regulation 28 notice.”

Source location

Response from East Sussex County Council
Page 1 · response
Published 28 June 2021

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

Established electronic, verbal and hard-copy information-sharing routes, supported by a 24-hour crisis team, provide access to relevant patient information.

Verbatim wording from the response

“Regarding accessibility of relevant patient clinical information, I would like to assure you that it has long been the case that ESCC have had access to the Trust’s electronic record system, Carenotes, to enable patient information to be accessible to them. The expectation is that the ESCC AMHP would access the necessary information and appropriately share it with any independent s.12 doctor who does not have access. In addition, it has been the working practice for many years that the Trust also shares information verbally and/or by providing hard copies of relevant patient records to AMHPs and to independent s.12 doctors, as needed. This further communication route facilitates the sharing of information if, for any reason, electronic access to Carenotes is not achievable.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 28 June 2021

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.3

  1. 1

    Update the Approved Mental Health Practitioner warranting and re-warranting process to require completion and presentation of a dynamic risk assessment.

    Stated by East Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
  2. 2

    Regularly review the implemented actions and update or amend them where appropriate.

    Stated by East Sussex County CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
  3. 3

    Share ESCC’s practice changes with Trust doctors who work as independent s.12 doctors.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    ESCC is responsible for recruiting, training, warranting and managing Approved Mental Health Practitioners.

    Stated by Sussex Partnership NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Update the Approved Mental Health Practitioner warranting and re-warranting process to require completion and presentation of a dynamic risk assessment.

Verbatim wording from the response

“(3) The AMHP warranting and re-warranting process has been updated. A dynamic risk assessment has to be completed and presented to the assessing team. It is now part of the process that AMHPs undergo as part of the warrant and re-warranting process.”

Source location

Response from East Sussex County Council
Page 2 · response
Published 28 June 2021

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

Regularly review the implemented actions and update or amend them where appropriate.

Verbatim wording from the response

“The actions the Council has undertaken above will be regularly reviewed and updated/amended if appropriate”

Source location

Response from East Sussex County Council
Page 2 · response
Published 28 June 2021

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

Share ESCC’s practice changes with Trust doctors who work as independent s.12 doctors.

Verbatim wording from the response

“Trust (the ‘Trust’) and ESCC, about your concerns, has not occurred as yet. However, I am pleased to be able to assure you that the Trust’s Deputy Chief Nurse has contacted ████████ at ESCC to obtain details of the changes they have made to enable the Trust to gain a full understanding. The Trust will then facilitate the sharing of that information with the Trust’s doctors to ensure that those who also work as independent s.12 doctors, at the behest of ESCC, do so in the knowledge of ESCC’s changes in practice.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 28 June 2021

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

ESCC is responsible for recruiting, training, warranting and managing Approved Mental Health Practitioners.

Verbatim wording from the response

“Your office has helpfully shared the Response provided to you by East Sussex County Council (ESCC) and I note that they have explained their responsibility for the recruitment, training, warranting and management of the Approved Mental Health Practitioners (AMHPs) and provided details of changes that they have initiated. It is regrettable that a direct discussion, between Sussex Partnership NHS Foundation”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 28 June 2021

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