PFD report

Mr Paz Ogbe-Millar · Prevention of Future Deaths report

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Issued 5 Feb 2024•North London

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
8

Described in 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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Report evidence summary

Concerns raised1

  1. Lack of consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department
    Part of recurring concern: Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessmentPart of recurring concern: Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pendingPart of recurring concern: Unsafe emergency department care environments for people in mental health crisis
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.1

  1. Action

    Refine mental-health assessment tools and replace the previous proforma with an electronic assessment aligned with the current observation-level SOP.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.

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 consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department

Wider context from the report

“a. Evidence was heard regarding the appropriate level of observation by Emergency Department staff of mental health patients waiting in the Emergency Department (operated by WHTHNT) to be seen by the Mental Health Liaison Team (operated by HPUNFT). There was confusion amongst the WHTHNT witnesses as to the appropriate level of observation. This was contributed to by a lack of clarity in WHTHNT’s (a) Standing Operating Procedure entitled: “Management of Mental Health Patients in the Emergency Department (ED) at Watford General Hospital (WGH): Standing Operating Procedure (SOP), Issue date August 2021”; when compared with (b) WHTHNT’s “Emergency Department Adult Mental Health Pro-forma” Version 3, Undated (“EDP”); b. The SOP states in a section titled “5. Procedure” (on page 4 of 16) “Patients at moderate or high risk of self-harm or of leaving before assessment and treatment should be observed closely whilst in the ED. There should be continuous observation, and this should be documented in the mental health presentation engagement record (Appendix 1); c. Whereas the EDP states at page 7 under the heading: “Summary of levels of risk and suggested action”, the following: “Low: No special observations required Medium: Consider 15-minute special observation”; d. Emphasis has been added above to paragraphs (b) and (c) in bold text; e. My concern is that the inconsistency between these two documents creates a risk that mental health patients admitted at medium risk of self-harm awaiting assessment for their mental health condition in the Emergency Department may not be subjected to an appropriate level of observation. ”

Is this part of a recurring concern?

Yes — Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessment; Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending; Unsafe emergency department care environments for people in mental health crisis.

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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

Refine mental-health assessment tools and replace the previous proforma with an electronic assessment aligned with the current observation-level SOP.

Verbatim wording from the response

“We have collaborated with the Royal Free London NHS Foundation Trust to refine our assessment tools for patients with mental health needs, ensuring accurate identification of the appropriate level of observation. Consequently, the previously used proforma has been replaced by an electronic assessment which aligns with the current SOP, eliminating any inconsistencies between the two documents.”

Source location

Response from West Hertfordshire Teaching Hospital
Page 1 · response
Published 14 February 2024

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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.7

  1. 1

    Approve the Patient Safety Incident Response Plan and Patient Safety Incident Response Framework Policy for implementation, including mental-health priorities.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
  2. 2

    Reflect mental-health themes from the approved safety plans in Quality Account Priorities.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
  3. 3

    Recruit a Matron for Mental Health to improve the quality of care.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
  4. 4

    Update policies to set expectations for staff regarding mental-health care.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
  5. 5

    Collaborate with mental-health partnership teams to implement a Suicide Prevention Pathway Pilot.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
  6. 6

    Implement an electronic patient record system to improve access to information and refine mental-health assessment tools.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
  7. 7

    Deliver a mental-health awareness week in May 2024 to set expectations for staff.

    Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.

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

Approve the Patient Safety Incident Response Plan and Patient Safety Incident Response Framework Policy for implementation, including mental-health priorities.

Verbatim wording from the response

“- The Patient Safety Incident Response Plan (PSIRP) and PSIRF Policy have been approved for implementation, focusing on key themes including mental health, which will be reflected in our Quality Account Priorities. (Completed Jan 2024)”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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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

Reflect mental-health themes from the approved safety plans in Quality Account Priorities.

Verbatim wording from the response

“- The Patient Safety Incident Response Plan (PSIRP) and PSIRF Policy have been approved for implementation, focusing on key themes including mental health, which will be reflected in our Quality Account Priorities. (Completed Jan 2024)”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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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

Recruit a Matron for Mental Health to improve the quality of care.

Verbatim wording from the response

“- Recruitment of a Matron for Mental Health to elevate the quality of care. (due to be completed by the end of April 2024).”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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

Update policies to set expectations for staff regarding mental-health care.

Verbatim wording from the response

“- Policy updates and a planned mental health awareness week (May 2024) to set expectations for staff.”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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

Collaborate with mental-health partnership teams to implement a Suicide Prevention Pathway Pilot.

Verbatim wording from the response

“- Collaboration with Mental Health partnership teams to implement a Suicide Prevention Pathway Pilot is underway.”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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

Implement an electronic patient record system to improve access to information and refine mental-health assessment tools.

Verbatim wording from the response

“- Implementation of an electronic patient record system to improve access to patient information and refine assessment tools for mental health patients. (Completed Nov 2021)”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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

Deliver a mental-health awareness week in May 2024 to set expectations for staff.

Verbatim wording from the response

“- Policy updates and a planned mental health awareness week (May 2024) to set expectations for staff.”

Source location

Response from West Hertfordshire Teaching Hospital
Page 2 · response
Published 14 February 2024

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

Official responses located
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Data last updated 7 September 2026