PFD report

Terence Joseph Pimm · Prevention of Future Deaths report

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Issued 14 Aug 2017•Essex

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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: 11
Recipients: 3
Responses found: 2
Stated actions: 16

Recipients and published responses

Essex Partnership University NHS Foundation TrustResponse found Essex PoliceResponse found The Essex Community Rehabilitation Company LimitedNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 30 August 2016 I commenced an investigation into the death of Terence Joseph Pimm. The investigation concluded at the end of the inquest on 21 April 2017. The conclusion of the inquest was a narrative conclusion

Concerns and recipient responses

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

Concerns raised11

Insufficient guidance
Insufficient coordination between the police, hospital Trust and probation service
Failure of call handling at The Lakes

Responses linked to these concerns

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

Actions described in response 13

Action
Raise the Prevention of Future Deaths report at the scheduled health-partner meeting to reinforce the importance of the proposed information-sharing agreements.
Stated by Essex PoliceStated planned
Action
Develop information-sharing agreements and standard operating procedures with health partners for reciprocal disclosure of serious-harm risk information.
Stated by Essex PoliceStated in progress
Action
Supplement Force Control Room call-handler training with guidance on assessing immediacy, welfare risks, and when to seek advice.
Stated by Essex PoliceStated completed

Action
Require custody-suite telephone calls to be handled by police personnel, relevant detainee information recorded, and unrelated calls transferred to the Force Control Room.
Stated by Essex PoliceStated completed
Action
Operate a street-triage team pairing mental health practitioners with dedicated police officers.
Stated by Essex Partnership University NHS Foundation TrustStated completed
Action
Deliver training on the warrant-related flowchart to mental health accident and emergency and criminal justice teams.
Stated by Essex Partnership University NHS Foundation TrustStated in progress
Action
Continue developing electronic record-keeping processes for health-based place-of-safety information.
Stated by Essex Partnership University NHS Foundation TrustStated in progress
Action
Audit family involvement and communications through the staff supervision process.
Stated by Essex Partnership University NHS Foundation TrustStated in progress
Action
Reinforce to staff the importance of family involvement and ongoing communications.
Stated by Essex Partnership University NHS Foundation TrustStated completed
Action
Ensure the probation service is invited to local police liaison emergency care meetings to improve information sharing.
Stated by Essex Partnership University NHS Foundation TrustStated planned
Action
Provide staff with a flowchart specifying actions for situations involving people subject to a warrant.
Stated by Essex Partnership University NHS Foundation TrustStated completed
Action
Reinforce the information-sharing concordat between police, hospital and probation services.
Stated by Essex Partnership University NHS Foundation TrustStated completed
Action
Route all health-based place-of-safety calls through the Trust call centre for recording and call-log documentation by trained handlers.
Stated by Essex Partnership University NHS Foundation TrustStated completed

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 3

1
Route public calls unrelated to current detainees from switchboard operators to the Force Control Room rather than custody suites.
Stated by Essex PoliceStated completed
2
Maintain individual patient records for health-based place-of-safety admissions, including risks, presentation assessments and documentation from other agencies.
Stated by Essex Partnership University NHS Foundation TrustStated completed
3
Share learning from Mr Pimm’s death across the Trust to prevent recurrence of the identified issues.
Stated by Essex Partnership University NHS Foundation TrustStated in progress

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised11

Insufficient guidance

Insufficient coordination between the police, hospital Trust and probation service

Failure of call handling at The Lakes

Insufficient training

Failure of mental health assessors to seek family input in appropriate circumstances

Failure of police call handlers to assess whether an individual is objectively at immediate risk

Failure of record-keeping at the police custody suite

Failure of call handling at the police custody suite

Failure of record-keeping at The Lakes

Failure of mental health clinicians to understand the effect of warrants on their ability to assess and treat

Insufficient information sharing between the police, hospital Trust and probation service

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.13

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

Actions described in response 13

Recipient-stated actions 3