PFD report

Nigel Malloy · Prevention of Future Deaths report

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Issued 19 Jul 2018•Southampton and New Forest

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

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 raised3

  1. Failure to share information between alcohol liaison and inclusion services
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
  2. Failure to provide follow-up after emergency department admissions for alcohol-related presentations
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
  3. Lack of a coordinated plan to treat alcohol dependence
    Part of recurring concern: Failure to provide continuity of patient carePart of recurring concern: Unreliable care and protection arrangements for people with chronic alcohol dependence
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

    Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.

    Stated by Hampshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2018.
  2. Action

    Participate in a monthly multi-provider High Intensity User Group to identify further support for frequent attenders.

    Stated by Hampshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2018.
  3. Action

    Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.

    Stated by Hampshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2018.

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

  1. Position

    Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.

    Stated by Hampshire Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 share information between alcohol liaison and inclusion services

Wider context from the report

“The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable inter-agency information sharing for coordinated care.

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

Failure to provide follow-up after emergency department admissions for alcohol-related presentations

Wider context from the report

“The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge.

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 a coordinated plan to treat alcohol dependence

Wider context from the report

“The Deceased was alcohol dependant and suffered depressive symptoms. On 22 May 2017 he fell from a window in circumstances very similar to those on 29 October 2017 and on that occasion suffered head injuries and was taken to Southampton General Hospital. After this fall he was regularly drinking excess alcohol leading to multiple admissions to the Emergency Department at Royal Hampshire County Hospital Winchester operated by Hampshire Hospitals NHS Foundation Trust (HHFT), but was then discharged once sober without any follow up. On 22 September 2017 he referred himself to the Inclusion Service provided by South Staffordshire & Shropshire NHS Foundation Trust (SSSFT) and started to receive some assistance. On 16 October 2017 the deceased sustained a fall in the street and was taken to Winchester hospital for treatment of his head wound but discharged the same day. There was no sharing of information between the Alcohol Liaison service provided by HHFT and the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of patient care; Unreliable care and protection arrangements for people with chronic alcohol dependence.

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

Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.

Verbatim wording from the response

“• A 24 hour referral service and dedicated pathway with Inclusion”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Participate in a monthly multi-provider High Intensity User Group to identify further support for frequent attenders.

Verbatim wording from the response

“• Monthly High Intensity User Group involving multiple providers to discuss whether there is any further support which can be provided to high intensity users such as Mr Malloy”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.

Verbatim wording from the response

“• Regular telephone liaison between Inclusion and the Trust when one of their users is an inpatient or in relation to referrals”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Provide alcohol-service inpatient access through weekly and arranged ad hoc Inclusion inreach.

Verbatim wording from the response

“• At the time of Mr Malloy’s admissions to the Trust, Inclusion were running a weekly inreach service on a Sunday.”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.

Verbatim wording from the response

“As per our response to point 2 above, the Trust made the initial referral to Inclusion on 21.09.17 and subsequently liaised with them to arrange Mr Malloy’s first attendance and ensure that Mr Malloy had attended as planned.”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 2 · response
Published 23 September 2018

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

    Continue discussions with commissioners and health and social care services to improve quality and access to relevant services.

    Stated by Hampshire Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
  2. 2

    Make referrals to the Mental Health Provider for assessment.

    Stated by Hampshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2018.
  3. 3

    Provide patients with leaflets and information about the Inclusion Service.

    Stated by Hampshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2018.

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

Continue discussions with commissioners and health and social care services to improve quality and access to relevant services.

Verbatim wording from the response

“• There are ongoing discussions between Public Health England Commissioners, Hampshire County Council, Mental Health Services and Primary and Secondary Care to improve the quality and access to services for those impacted by these types of illness.”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Make referrals to the Mental Health Provider for assessment.

Verbatim wording from the response

“• Referrals made to Mental Health Provider for assessment”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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

Provide patients with leaflets and information about the Inclusion Service.

Verbatim wording from the response

“• Leaflets available about Inclusion Service to provide to patients”

Source location

2018-0232-Response-by-Hampshire-Hospitals-NHS-Trust
Page 3 · response
Published 23 September 2018

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