PFD report

Andrew Gus PEEBLES · Prevention of Future Deaths report

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Issued 13 Jun 2016•Preston and West Lancashire

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
11

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised11

  1. Failure of RMNs to record post-consultation and post-review information in ACC T documentation
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
  2. Failure to undertake assessments in the way recommended for prisoner safety
    Part of recurring concern: Unreliable safety risk assessments for prisoners
  3. Failure to undertake referred psychiatric assessment
    Part of recurring concern: Unreliable mental health referral pathways
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 RMNs to record post-consultation and post-review information in ACC T documentation

Wider context from the report

“(2) No entries were made by the RMN after consultations/ACC T reviews with the deceased in the ACC T documentation resulting in no information being available to discipline officers managing Mr Peebles ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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 undertake assessments in the way recommended for prisoner safety

Wider context from the report

“(9) the attendance at inquest by the healthcare manager without sufficient information to demonstrate that matters had improved, been resolved etcetera and having heard the suggestions to minimise future deaths by the expert ████████ consultant forensic psychiatrist who advises at a national level on matters of prisoner safety, effectively responded that that wasn't the way the Trust undertook its assessments ”

Is this part of a recurring concern?

Yes — Unreliable safety risk assessments for prisoners.

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 undertake referred psychiatric assessment

Wider context from the report

“(7) on referral on 25 May 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 RMNs to make medical-record enquiries about self-harm or suicide responses

Wider context from the report

“(1) No enquiries were made by the RMN in the medical records specifically commenting upon the replies to questions in respect of self-harm or suicide, the only significant entries in the medical records on this subject being made by RGNs ”

Is this part of a recurring concern?

Yes — Unreliable assessment of suicide and self-harm risk.

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 RMNs to read ACC T documentation for collateral information relevant to delusional-disorder diagnosis

Wider context from the report

“(4) No reading by the RMN of the ACC T documentation for collateral information necessary to assist in the diagnosis of a delusional disorder ”

Is this part of a recurring concern?

Yes — Unreliable gathering and use of collateral information in mental health assessments.

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

Reliance by RMNs on summaries of ACC T documentation instead of independent review

Wider context from the report

“(5) RMN relying upon the summary of the ACC T documentation provided to her by the Senior Officer undertaking the ACC T review rather than assessing the documentation for herself to form a view of the information from a mental health perspective ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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

Formation of mental health conclusions without reviewing relevant documentation or undertaking mental health assessment

Wider context from the report

“(6) RMN formed the view that Mr Peebles was not suffering from any mental health condition without having reviewed the ACC T documentation, discipline documentation or undertaking any mental health assessment prior to informing the deceased of her decision. ”

Is this part of a recurring concern?

Yes — Inadequate mental health assessment before care decisions.

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 record referrals concerning psychiatric state in the medical record

Wider context from the report

“(7) on referral on 25 May 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place ”

Is this part of a recurring concern?

Yes — Unreliable recording of safety-critical mental health information.

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 RMNs to assess patients with obvious delusional symptoms

Wider context from the report

“(3) No assessment by an RMN of a patient suffering obviously delusional symptoms on several occasions ”

Is this part of a recurring concern?

Yes — Failure to recognise and adequately assess clinically significant psychotic symptoms.

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 sufficient information demonstrating improvement or resolution of safety matters

Wider context from the report

“(9) the attendance at inquest by the healthcare manager without sufficient information to demonstrate that matters had improved, been resolved etcetera and having heard the suggestions to minimise future deaths by the expert ████████ consultant forensic psychiatrist who advises at a national level on matters of prisoner safety, effectively responded that that wasn't the way the Trust undertook its assessments ”

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 supervision or retraining for RMNs remaining in clinical posts

Wider context from the report

“(8) RMN remains in the clinical post within the trust and does not appear to have undergone any supervision or retraining ”

Is this part of a recurring concern?

Yes — Failure to supervise clinicians during clinical work.

Open source report
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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