Emma Carpenter · Prevention of Future Deaths report

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Issued 14 Jul 2015•Nottinghamshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
13

Described in responses

Recipients and published responses

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 raised5

  1. Lack of inpatient beds for mentally ill children and adolescents
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
  2. Lack of sustainable long-term commissioning for specialist eating disorder services for children and adolescents
  3. Lack of clear connections between mental health professionals and education pastoral care staff
    Part of recurring concern: Failure to integrate mental health and education pastoral services

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. NHS England

    Invest £30 million annually to enable CCGs to develop and deliver evidence-based community eating-disorder services.

  2. NHS England

    Publish an access and waiting-time standard and commissioning guidance for evidence-based community eating-disorder services.

  3. NHS England

    Invest in inpatient CAMHS capacity and increase eating-disorder bed availability in the East Midlands and nationally.

  4. NHS England

    Develop national service specifications requiring acute inpatient CAMHS units to manage eating disorders and other mental illnesses.

  5. NHS England

    Plan a procurement process to commission inpatient beds according to assessed need rather than historical provision.

  6. NHS England

    Pilot a single point-of-access programme linking specialist community CAMHS with schools across at least 15 CCGs, including joint NHS and school staff training.

  7. NHS England

    Commission specialist inpatient eating-disorder units nationally.

  8. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

    Continue engaging with Nottinghamshire Healthcare Trust’s services when paediatric support is needed.

  9. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

    Monitor the support arrangements through the paediatric clinical governance team.

  10. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

    Offer a formal service-level agreement to support Bassetlaw patients receiving treatment at Thorneywood Adolescent Unit.

  11. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

    Identify a consultant to act as the link with Nottinghamshire Healthcare Trust’s eating disorder services.

  12. George Freeman MP

    Provide £7 million to expand children’s and adolescents’ mental health provision, including Tier 4 beds, case managers, access protocols and case management.

  13. George Freeman MP

    Publish guidance to commissioners on maximising school nursing teams’ contribution to the health of school-aged children.

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

  1. NHS England

    NHS England understood that inpatient beds were available when the death occurred, disputing a premise of insufficient bed availability.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

    Regular paediatric support at Thorneywood Adolescent Unit is not anticipated; case-by-case paediatric advice is considered adequate if required.

    Existing 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

Lack of inpatient beds for mentally ill children and adolescents

Wider context from the report

“2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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 sustainable long-term commissioning for specialist eating disorder services for children and adolescents

Wider context from the report

“1. Although the Trust has now set up a specialist Eating Disorder Service for children and adolescents, there is only short term funding in place for this service and a lack of commitment from Commissioners for its long term future. ”

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

Lack of clear connections between mental health professionals and education pastoral care staff

Wider context from the report

“4. In the absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health and education pastoral services.

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 of school nurses to attend multidisciplinary meetings reliably

Wider context from the report

“3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses. ”

Is this part of a recurring concern?

Yes — Unsafe operation of multidisciplinary clinical meetings.

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 professional links between the specialist Eating Disorder Service and Bassetlaw Hospital

Wider context from the report

“1. The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen’s Medical Centre, there are no equivalent links with Bassetlaw Hospital. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Invest £30 million annually to enable CCGs to develop and deliver evidence-based community eating-disorder services.

Verbatim wording from the response

“NHS England is investing £30m per year for Clinical Commissioning Groups (CCG’s) to develop and deliver evidence based community Eating Disorder services. This funding is in addition to resources already in place to deliver treatment for young people with eating disorders. In July 2015 NHS England published an access and waiting time standard and commissioning guidance on how the additional funds are to be used to commission evidence based community Eating Disorder services for children and young people (http://www.bing.com/search?q=access+and+waiting+time+standard+for+children+and+young+people+with+an+eating+disorder&src=IE-TopResult&FORM=IE10TR&adlt=strict). This is to support CCG’s preparation to meet a new standard for evidence based eating disorder treatment to be delivered within a maximum of 4 weeks from first contact for routine cases and 2 weeks for urgent cases.”

Source location

2015-0276-Response-by-NHS-England
Page 2 · response
Published 14 July 2015

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

Publish an access and waiting-time standard and commissioning guidance for evidence-based community eating-disorder services.

Verbatim wording from the response

“NHS England is investing £30m per year for Clinical Commissioning Groups (CCG’s) to develop and deliver evidence based community Eating Disorder services. This funding is in addition to resources already in place to deliver treatment for young people with eating disorders. In July 2015 NHS England published an access and waiting time standard and commissioning guidance on how the additional funds are to be used to commission evidence based community Eating Disorder services for children and young people (http://www.bing.com/search?q=access+and+waiting+time+standard+for+children+and+young+people+with+an+eating+disorder&src=IE-TopResult&FORM=IE10TR&adlt=strict). This is to support CCG’s preparation to meet a new standard for evidence based eating disorder treatment to be delivered within a maximum of 4 weeks from first contact for routine cases and 2 weeks for urgent cases.”

Source location

2015-0276-Response-by-NHS-England
Page 2 · response
Published 14 July 2015

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

Invest in inpatient CAMHS capacity and increase eating-disorder bed availability in the East Midlands and nationally.

Verbatim wording from the response

“Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.”

Source location

2015-0276-Response-by-NHS-England
Page 1 · response
Published 14 July 2015

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

Develop national service specifications requiring acute inpatient CAMHS units to manage eating disorders and other mental illnesses.

Verbatim wording from the response

“Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.”

Source location

2015-0276-Response-by-NHS-England
Page 1 · response
Published 14 July 2015

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

Plan a procurement process to commission inpatient beds according to assessed need rather than historical provision.

Verbatim wording from the response

“Further to the additional beds already commissioned by NHS England, we are currently in the planning stage of a procurement process which will help to ensure that we commission inpatient beds according to need rather than based on history.”

Source location

2015-0276-Response-by-NHS-England
Page 1 · response
Published 14 July 2015

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

Pilot a single point-of-access programme linking specialist community CAMHS with schools across at least 15 CCGs, including joint NHS and school staff training.

Verbatim wording from the response

“• NHS England are about to pilot an initiative with the Department for Education to develop a programme for single points of access in Tier 3 (specialist community) CAMHS and schools, testing it over at least 15 CCGs. The training will be for an identified member of staff from the NHS CAMHS team plus a member of the school staff and additional colleagues such as, Special Educational Needs Co-ordinators, school nurses and counsellors. This is linked to a recommendation from Future in Mind. The Spring Budget allocated £1.5 million to support this pilot over the next year from July 2015 to June 2016.”

Source location

2015-0276-Response-by-NHS-England
Page 3 · response
Published 14 July 2015

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

Commission specialist inpatient eating-disorder units nationally.

Verbatim wording from the response

“Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.”

Source location

2015-0276-Response-by-NHS-England
Page 1 · response
Published 14 July 2015

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

Continue engaging with Nottinghamshire Healthcare Trust’s services when paediatric support is needed.

Verbatim wording from the response

““Thank you for your letter of 20th July 2015 regarding the Regulation 28. Following our conversation, we cannot anticipate any regular requirement from Doncaster and Bassetlaw Hospitals NHS Foundation Trust to provide paediatric support at Thorneywood Adolescent Unit. I am sure it would be adequate to agree any paediatric advice on a case by case basis should this ever be required. Please do get back to me if you need anything else.””

Source location

2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust
Page 1 · response
Published 14 July 2015

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

Monitor the support arrangements through the paediatric clinical governance team.

Verbatim wording from the response

“We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team.”

Source location

2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust
Page 1 · response
Published 14 July 2015

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

Offer a formal service-level agreement to support Bassetlaw patients receiving treatment at Thorneywood Adolescent Unit.

Verbatim wording from the response

“I wish to confirm that this Trust has communicated formally to Nottinghamshire Health Care Foundation Trust, to understand how we can support patients from the Bassetlaw area whilst receiving treatment in Thorneywood Adolescent Unit. We offered a formal service level agreement and a named consultant to be the link to the service.”

Source location

2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust
Page 1 · response
Published 14 July 2015

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

Identify a consultant to act as the link with Nottinghamshire Healthcare Trust’s eating disorder services.

Verbatim wording from the response

“I wish to confirm that this Trust has communicated formally to Nottinghamshire Health Care Foundation Trust, to understand how we can support patients from the Bassetlaw area whilst receiving treatment in Thorneywood Adolescent Unit. We offered a formal service level agreement and a named consultant to be the link to the service.”

Source location

2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust
Page 1 · response
Published 14 July 2015

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 £7 million to expand children’s and adolescents’ mental health provision, including Tier 4 beds, case managers, access protocols and case management.

Verbatim wording from the response

“On the issue of in-patient bed provision, DH provided NHS England with £7million in 2014/15 in response to an NHS England Tier 4 Report, published in July 2014. This funding was to provide: around 50 extra Children and Adolescents Mental Health Service (CAMHS) Tier 4 beds for young patients in the areas with the least provision (South West and Yorkshire). Also additional case managers, new standardised access protocols throughout the country, and a new case management system to make the best use of existing resources.”

Source location

2015-0276-Response-by-Department-of-Health
Page 1 · response
Published 14 July 2015

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

Publish guidance to commissioners on maximising school nursing teams’ contribution to the health of school-aged children.

Verbatim wording from the response

“In April 2014 Public Health England (PHE) and the Department of Health published guidance to commissioners for services to school aged children, Maximising the school nursing team contribution to the public health of school-aged children. At an England-wide level, during the 2014 planning round, NHS employers of school nurses indicated that they currently have some high levels of vacancies.”

Source location

2015-0276-Response-by-Department-of-Health
Page 2 · response
Published 14 July 2015

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

NHS England understood that inpatient beds were available when the death occurred, disputing a premise of insufficient bed availability.

Verbatim wording from the response

“Whilst it is our understanding that there were beds available at the time of this tragic death, NHS England also recognises the importance of appropriate community eating disorder services and gaps in this provision across the country. This is reflected in the recent report of the Children and Young People’s Mental Health Taskforce ‘Future in”

Source location

2015-0276-Response-by-NHS-England
Page 1 · response
Published 14 July 2015

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

Regular paediatric support at Thorneywood Adolescent Unit is not anticipated; case-by-case paediatric advice is considered adequate if required.

Verbatim wording from the response

““Thank you for your letter of 20th July 2015 regarding the Regulation 28. Following our conversation, we cannot anticipate any regular requirement from Doncaster and Bassetlaw Hospitals NHS Foundation Trust to provide paediatric support at Thorneywood Adolescent Unit. I am sure it would be adequate to agree any paediatric advice on a case by case basis should this ever be required. Please do get back to me if you need anything else.””

Source location

2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust
Page 1 · response
Published 14 July 2015

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