PFD report

George Edward Rogers · Prevention of Future Deaths report

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Issued 21 Nov 2019•West 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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised1

  1. Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS
    Part of recurring concern: Failure to ensure timely Lead Practitioner appointment for mental health patientsPart of recurring concern: Unreliable community Home Treatment Team care pathwaysPart of recurring concern: Unsafe coordination and continuity during mental health service transfers
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

    Monitor weekly patients transferred between teams who remain without an allocated Lead Practitioner.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2019.
  2. Action

    Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2019.

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

  1. Position

    There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.

    Stated by Sussex Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 appoint a Lead Practitioner when transferring patients between the CRHTT and ATS

Wider context from the report

“1. When transferring patients between the CRHTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely Lead Practitioner appointment for mental health patients; Unreliable community Home Treatment Team care pathways; Unsafe coordination and continuity during mental health service transfers.

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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

Monitor weekly patients transferred between teams who remain without an allocated Lead Practitioner.

Verbatim wording from the response

“Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 27 November 2019

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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

Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.

Verbatim wording from the response

“The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 27 November 2019

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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

There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.

Verbatim wording from the response

“I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, if any further clarification is required or I can assist further in any way then please do not hesitate to contact me.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 27 November 2019

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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

Existing monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.

Verbatim wording from the response

“If the patient is already known to the team, the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 27 November 2019

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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