PFD report

Michael Joseph HINDES · Prevention of Future Deaths report

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Issued 20 Oct 2023•Inner 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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 refer patients to the crisis team during delays in community mental health follow-up
    Part of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Unreliable interim mental health support during care transitionsPart of recurring concern: Unreliable mental health referral pathways
  2. Failure to make sufficient efforts to involve patients’ families in mental health care
  3. Delays in community mental health team follow-up
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Failure to provide timely continuing mental health reviews and follow-up
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

    Continue participating in the national Triangle of Care initiative to strengthen engagement among patients, families, carers and professionals.

    Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2023.
  2. Action

    Develop and issue a Monthly Learning Bulletin article reminding Trust staff how to hold meaningful conversations about sharing information with families and document them.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  3. Action

    Change Psychiatric Liaison Team local protocols to strengthen prompts reminding clinicians how to approach information sharing and family engagement.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.

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

  1. Position

    The patient had capacity and refused family information-sharing, so disclosure without consent would have been unlawful, although further exploration was warranted.

    Stated by South West London and St George'S Mental Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 refer patients to the crisis team during delays in community mental health follow-up

Wider context from the report

“He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. ”

Is this part of a recurring concern?

Yes — Failure to provide timely continuing mental health reviews and follow-up; Unreliable interim mental health support during care transitions; 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 to make sufficient efforts to involve patients’ families in mental health care

Wider context from the report

“He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. ”

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

Delays in community mental health team follow-up

Wider context from the report

“He was discharged with a plan for follow up by the community mental health team (CMHT). I was told that the local CMHT meets at the beginning of every week, and then there is sometimes a delay before an appointment is made, so it was likely that Michael would have to wait an absolute minimum of a week to be seen. In the meantime, it was not thought necessary to refer him to the crisis team. Michael’s family knew nothing of his mental ill health. He declined an invitation by the nurse assessing him to contact them. He did not want to worry them. Despite her awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the assessing nurse did not in any way try to persuade Michael to allow her to do this. The first that Michael’s family heard of Michael’s mental ill health was when they heard of his death. I am sure that, had they been made aware of it while he was still alive, they would have done everything in their power to support him and to engage with the mental health services. Families very often complain to me at inquest that mental health services have not done enough to try to bring them in to a patient’s care. In spite of the frequency of this occurrence, the lesson does not seem to be being learnt. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Failure to provide timely continuing mental health reviews and follow-up.

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

Continue participating in the national Triangle of Care initiative to strengthen engagement among patients, families, carers and professionals.

Verbatim wording from the response

“We agree with your general view that challenges remain and there is a need for improvements around how to best ensure positive engagement and sharing of information between the healthcare provider, patients, and their families and carers. We are committed to the national ‘Triangle of Care’ initiative that champions the bringing together of carers and relatives, service users and professionals. It aims to promote safety, aid recovery, and sustain the wellbeing of people with mental health issues and their carers and families. This remains a key area of focus for the Trust. The Psychiatric Liaison Team continue to reflect on this and will be changing their local”

Source location

Response from South West London and St George's Mental Health
Page 2 · response
Published 19 December 2023

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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

Develop and issue a Monthly Learning Bulletin article reminding Trust staff how to hold meaningful conversations about sharing information with families and document them.

Verbatim wording from the response

“As per your request with the PFD to raise awareness of this area, we will take the opportunity to raise awareness within the Trust via a specific newsletter article issued to Trust staff (known as our Monthly Learning Bulletin) to remind and promote how and when to best ensure there are meaningful conversations with patients around sharing information with families. This will focus on the Triangle of Care approach and provide clarity around the delicate balance between encouraging patients whilst respecting their wishes and ensuring this is clearly documented. This will be developed and issued by March 2024.”

Source location

Response from South West London and St George's Mental Health
Page 3 · response
Published 19 December 2023

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

Change Psychiatric Liaison Team local protocols to strengthen prompts reminding clinicians how to approach information sharing and family engagement.

Verbatim wording from the response

“We agree with your general view that challenges remain and there is a need for improvements around how to best ensure positive engagement and sharing of information between the healthcare provider, patients, and their families and carers. We are committed to the national ‘Triangle of Care’ initiative that champions the bringing together of carers and relatives, service users and professionals. It aims to promote safety, aid recovery, and sustain the wellbeing of people with mental health issues and their carers and families. This remains a key area of focus for the Trust. The Psychiatric Liaison Team continue to reflect on this and will be changing their local”

Source location

Response from South West London and St George's Mental Health
Page 2 · response
Published 19 December 2023

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 patient had capacity and refused family information-sharing, so disclosure without consent would have been unlawful, although further exploration was warranted.

Verbatim wording from the response

“The clinical assessment clearly concluded that the patient had capacity to make decisions and the assessing nurse was of the firm view that he was clear that he did not consent to information being shared with his family around his mental health and struggles.”

Source location

Response from South West London and St George's Mental Health
Page 2 · response
Published 19 December 2023

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

Clinical assessment found low self-harm risk, so discharge with routine CMHT referral rather than crisis services was considered appropriate.

Verbatim wording from the response

“As you are aware through the Inquest, the clinical risk assessment undertaken at the time by the assessing nurse in the Psychiatric Liaison Team deemed the patient to be of low risk of self-harm and that he was suitable to be discharged home. In addition, with a routine referral to the Community Mental Health Team (CMHT) for ongoing diagnosis/further assessment, as crisis services were not required at that time.”

Source location

Response from South West London and St George's Mental Health
Page 2 · response
Published 19 December 2023

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.1

  1. 1

    Share the PFD response and learning with the CQC and Integrated Care System commissioners to raise awareness and support wider improvement.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.

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

Share the PFD response and learning with the CQC and Integrated Care System commissioners to raise awareness and support wider improvement.

Verbatim wording from the response

“We will share this and our response to the PFD with the CQC and our Commissioners (Integrated Care System) as per your wish to help contribute to improving greater awareness of this area.”

Source location

Response from South West London and St George's Mental Health
Page 3 · response
Published 19 December 2023

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