PFD report

Mr Crutchley · Prevention of Future Deaths report

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Issued 28 Jan 2019•Manchester South

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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. Significant waits for talking therapies
    Part of recurring concern: Unreliable access to talking therapies
  2. Lack of specialist drug and alcohol workers within the Early Intervention Team
  3. Dependence of service-user interaction with specialist drug and alcohol professionals on self-referral
    Part of recurring concern: Unreliable integration of substance misuse services into patient care
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.3

  1. Action

    Develop dual-diagnosis champion roles, provide additional training, and cascade substance-use skills through a train-the-trainer model.

    Stated by Clare ParkerStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
  2. Action

    Review psychological-therapy waiting-list management and make monthly contact with people waiting.

    Stated by Clare ParkerStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
  3. Action

    Provide an additional psychological therapist to increase capacity for individual and family interventions.

    Stated by Clare ParkerStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.

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

  1. Position

    The waiting list resulted from insufficient psychological therapy capacity, rather than difficulties recruiting or retaining suitably qualified therapists.

    Stated by Clare ParkerDisputes 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

Significant waits for talking therapies

Wider context from the report

“Whilst the witness who gave evidence on behalf of the trust was unable to provide details of current waiting times, it is a matter of additional concern that at times significant wait can be encountered by service-users referred for talking therapies. The evidence before the court suggested such delays were often associated with difficulties recruiting and retaining appropriately qualified therapists. ”

Is this part of a recurring concern?

Yes — Unreliable access to talking therapies.

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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 specialist drug and alcohol workers within the Early Intervention Team

Wider context from the report

“It is a matter of concern that the Early Intervention Team does not include specialist drug and alcohol workers amongst its number. Such professionals work for external providers and interaction with service users appear to be dependent on self-referral. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Dependence of service-user interaction with specialist drug and alcohol professionals on self-referral

Wider context from the report

“It is a matter of concern that the Early Intervention Team does not include specialist drug and alcohol workers amongst its number. Such professionals work for external providers and interaction with service users appear to be dependent on self-referral. ”

Is this part of a recurring concern?

Yes — Unreliable integration of substance misuse services into patient care.

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

Develop dual-diagnosis champion roles, provide additional training, and cascade substance-use skills through a train-the-trainer model.

Verbatim wording from the response

“The Tameside EIT are in the process of developing roles for dual diagnosis champions within the team who will be supported to undertake additional training in relation to substance and alcohol use and cascade these skills within the team through a ‘train the trainer’ model. This will support the team to provide a comprehensive offer in relation to assessment of alcohol/substance use, risk assessment including impact of use on illness and other risks including risk to self, other, neglect, vulnerabilities and exploitation, education, motivational work, harm minimisation and encouraging and supporting referral to and engagement with specialist drug and alcohol services.”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 3 · response
Published 24 May 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

Review psychological-therapy waiting-list management and make monthly contact with people waiting.

Verbatim wording from the response

“The management of the waiting list for psychological interventions in the team has also been reviewed and now includes a process of making monthly contact with individuals on the waiting list to ensure they still wish to access therapy and to provide an update on current waiting times.”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 5 · response
Published 24 May 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

Provide an additional psychological therapist to increase capacity for individual and family interventions.

Verbatim wording from the response

“The Tameside EIT actively promote uptake of psychological interventions as there is a good evidence base for their effectiveness. This is a popular intervention with service users supported by the team and a high percentage of the service users supported by the team accept the offer of this intervention which can lead to a wait for the appropriate therapy to commence. In order to support the reduction in the wait for psychological interventions for individuals supported by the EIT, Tameside and Glossop CCG provided funding for an additional psychological therapist post within the team. This post was successfully recruited to and the practitioner commenced in post in December 2018. The practitioner is trained to”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 4 · response
Published 24 May 2019

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 waiting list resulted from insufficient psychological therapy capacity, rather than difficulties recruiting or retaining suitably qualified therapists.

Verbatim wording from the response

“The waiting list for talking therapies that was in place at the time that Conor was being supported by the EIT was as a result of not having sufficient capacity within the team to provide the level of psychological therapies required rather than difficulties in recruiting and retaining qualified staff.”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 4 · response
Published 24 May 2019

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

    Ensure staff who lack dual-diagnosis training access appropriate training opportunities.

    Stated by Clare ParkerStated plannedThe respondent said that this action was planned when they made their response on 24 May 2019.
  2. 2

    Scope validated measures for assessing alcohol and substance dependency within physical health assessments.

    Stated by Clare ParkerStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
  3. 3

    Train practitioners to provide family intervention through train-the-trainer and in-team training.

    Stated by Clare ParkerStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.

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

Ensure staff who lack dual-diagnosis training access appropriate training opportunities.

Verbatim wording from the response

“Training is provided to care coordinators and other professionals within the EIT in relation to co-morbid alcohol and substance use. Training includes dual diagnosis training, motivational interviewing (techniques to assess the person’s readiness for change and movement forward on level of change), updates on new and emerging substances and risk assessment. This has been provided in-house and by external providers. The majority of care coordinators within the team have previously undertaken dual diagnosis training and will attend refresher training as required. The EIT team manager will ensure that staff who have not completed training in this area will access appropriate training opportunities as soon as they are available. This will be monitored through the management supervision process.”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 3 · response
Published 24 May 2019

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

Scope validated measures for assessing alcohol and substance dependency within physical health assessments.

Verbatim wording from the response

“alcohol and substance use the team are in the process of scoping available validated measures to assess dependency, such as the Drug Abuse Screening Test (DAST), for utilisation as part of the physical health assessment process.”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 3 · response
Published 24 May 2019

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

Train practitioners to provide family intervention through train-the-trainer and in-team training.

Verbatim wording from the response

“provide both individual and family interventions. This has resulted in a reduction in the waiting times for therapy within the team. The current wait for CBTp for individuals with first episode psychosis is approximately 10 weeks and there is only 1 person waiting for CBTp who is being managed on the ‘At Risk Mental State’ (ARMS) pathway. In addition to this a practitioner within the team has also undergone ‘train the trainer’ training in Family Intervention and has completed a 5 day training programme within the team to equip practitioners with the skills to offer this intervention in order to improve capacity to respond to requests for this intervention in a timely manner. There is currently no wait for family intervention.”

Source location

2019-0032-Response-by-Pennine-Care-NHS-Trust
Page 5 · response
Published 24 May 2019

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