PFD report

Sharon Ann Halliwell · Prevention of Future Deaths report

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Issued 4 Aug 2017•Manchester West

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Lack of connectivity
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.2

  1. Action

    Amend relevant Standard Operating Procedures to require clinicians responding to red-flag alerts to contact the relevant team and obtain necessary risk and treatment information.

    Stated by North West Boroughs Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
  2. Action

    Develop and implement flags on RiO and IAPTUS records to alert clinicians when service users receive care from another Trust team.

    Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 December 2017.

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

  1. Position

    The RiO and IAPTUS systems cannot be wholly integrated into one electronic care record because of their composition.

    Stated by North West Boroughs 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

Lack of connectivity

Wider context from the report

“Whilst other issues addressed in evidence had been addressed by the Trust the issue of lack of connectivity as described had not been fully addressed. ”

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

Amend relevant Standard Operating Procedures to require clinicians responding to red-flag alerts to contact the relevant team and obtain necessary risk and treatment information.

Verbatim wording from the response

“• In addition to this, the Trust will amend all appropriate Standard Operating Procedures by March 2018 to ensure that where clinicians identify a red flag alert, they contact the relevant clinical team and ensure that they have all the clinical information they require in relation to risk and ongoing treatment plans.”

Source location

2017-0319-Response-by-North-West-Boroughs-Healthcare-NHS-Trust
Page 2 · response
Published 3 December 2017

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 and implement flags on RiO and IAPTUS records to alert clinicians when service users receive care from another Trust team.

Verbatim wording from the response

“• The RiO and IAPTUS patient information systems are not integrated and due to their composition it is not possible to wholly integrate them into one electronic care record. However, there is the option of applying a ‘flag’ system to the record of both RiO and IAPTUS which would alert the clinician that a service user is open to care from another team within the Trust. This function is currently being developed by the Trust’s Information Technology team who are aiming to have a solution designed, built, tested and implemented by the end of March 2018.”

Source location

2017-0319-Response-by-North-West-Boroughs-Healthcare-NHS-Trust
Page 2 · response
Published 3 December 2017

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

The RiO and IAPTUS systems cannot be wholly integrated into one electronic care record because of their composition.

Verbatim wording from the response

“• The RiO and IAPTUS patient information systems are not integrated and due to their composition it is not possible to wholly integrate them into one electronic care record. However, there is the option of applying a ‘flag’ system to the record of both RiO and IAPTUS which would alert the clinician that a service user is open to care from another team within the Trust. This function is currently being developed by the Trust’s Information Technology team who are aiming to have a solution designed, built, tested and implemented by the end of March 2018.”

Source location

2017-0319-Response-by-North-West-Boroughs-Healthcare-NHS-Trust
Page 2 · response
Published 3 December 2017

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

    Provide IAPT staff with RiO training so they can check for key clinical activity.

    Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  2. 2

    Inform clinicians in externally provided IAPT services about relevant learning, require them to ask patients about other mental-health support, and add these requirements to monitored procedures.

    Stated by North West Boroughs Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
  3. 3

    Disseminate weekly incident-learning themes through the staff e-bulletin and local team meetings, with borough-level assurance of discussion.

    Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.

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

Provide IAPT staff with RiO training so they can check for key clinical activity.

Verbatim wording from the response

“October 2017. IAPT staff have also received RiO training to enable them to check for key clinical activity.”

Source location

2017-0319-Response-by-North-West-Boroughs-Healthcare-NHS-Trust
Page 2 · response
Published 3 December 2017

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

Inform clinicians in externally provided IAPT services about relevant learning, require them to ask patients about other mental-health support, and add these requirements to monitored procedures.

Verbatim wording from the response

“• Finally, as not all of the IAPT team services within the Trust’s footprint are provided by North West Boroughs Healthcare NHS Foundation Trust there needs to be an additional mechanism in these areas for clinicians. In this respect, these clinicians will be made aware of the ‘theme of the week’ learning, and to ask all patients if they are receiving any support for their mental health needs from any other agency. This action will also be added to the Standard Operating Procedures as above and monitored for compliance via the usual monitoring arrangements.”

Source location

2017-0319-Response-by-North-West-Boroughs-Healthcare-NHS-Trust
Page 2 · response
Published 3 December 2017

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

Disseminate weekly incident-learning themes through the staff e-bulletin and local team meetings, with borough-level assurance of discussion.

Verbatim wording from the response

“• A “theme of the week” communication has been shared across the organisation to ensure that this learning is embedded. These themes are generated from learning identified from incidents, near misses and complaints and are disseminated to all staff each week in the Trust’s e-bulletin, which is called In View. To ensure all staff are made aware of the learning identified, the topics highlighted in this way also form part of the agenda at local Team Meetings as part of the Core Brief to all staff. The Assistant Clinical Directors for each of the Boroughs will seek assurance that this has been raised with each of the clinical teams across the organisation as they occur across”

Source location

2017-0319-Response-by-North-West-Boroughs-Healthcare-NHS-Trust
Page 1 · response
Published 3 December 2017

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