PFD report

Mr Robin Andrew Ward · Prevention of Future Deaths report

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Issued 18 Oct 2024•Northamptonshire

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.

View original report
Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised6

  1. Failure of crisis houses to provide ligature-safe environments
    Part of recurring concern: Insufficient and unsafe crisis-house provision for patients needing crisis care
  2. Excessive distance of out-of-area acute beds from patients’ home addresses
    Part of recurring concern: Out-of-area mental health placements failing to provide effective continuity of care and support
  3. Insufficient clinical capacity and skills mix in crisis houses
    Part of recurring concern: Insufficient and unsafe crisis-house provision for patients needing crisis 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

    Recruit and specially train 8,500 additional mental health workers, including to support people at risk of suicide.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
  2. Action

    Request an NHS England report from the relevant integrated care board on local actions to prevent recurrence.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
  3. Action

    Continue working with the NHS to maximise mental health service capacity.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026.

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

  1. Position

    Local ICBs and authorities are responsible for arranging crisis house provision and addressing concerns about specific facilities.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 of crisis houses to provide ligature-safe environments

Wider context from the report

“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

Is this part of a recurring concern?

Yes — Insufficient and unsafe crisis-house provision for patients needing crisis 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

Excessive distance of out-of-area acute beds from patients’ home addresses

Wider context from the report

“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

Is this part of a recurring concern?

Yes — Out-of-area mental health placements failing to provide effective continuity of care and support.

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

Insufficient clinical capacity and skills mix in crisis houses

Wider context from the report

“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

Is this part of a recurring concern?

Yes — Insufficient and unsafe crisis-house provision for patients needing crisis 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

Insufficient provision of acute mental health beds

Wider context from the report

“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

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

Insufficient availability of out-of-area acute beds for elderly patients

Wider context from the report

“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

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

Delays in psychological assessment

Wider context from the report

“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services.

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

Recruit and specially train 8,500 additional mental health workers, including to support people at risk of suicide.

Verbatim wording from the response

“Finally, turning to your concerns around long waiting times to access a psychological assessment, it is unacceptable that too many people are not receiving the mental health care they need when they need it and we know that waits for mental health services are far too long. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that is where when people need it, we will make sure that mental health care is delivered in the community where appropriate, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. We will also recruit an additional 8,500 mental health workers to cut waiting times and provide faster treatment which will also help ease pressure on busy mental health services. These new workers will be specially trained to support people at risk of suicide.”

Source location

Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026

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

Request an NHS England report from the relevant integrated care board on local actions to prevent recurrence.

Verbatim wording from the response

“Where there are concerns about the provision provided in specific crisis houses, local ICBs and/or local authorities are best placed to address these as the organisations responsible for decisions about the provision of services in their area. I have asked NHS England to provide me with a report from the ICB detailing the local position so that I can understand what actions are being taken locally to prevent such a case from happening again.”

Source location

Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026

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 working with the NHS to maximise mental health service capacity.

Verbatim wording from the response

“I am sure you will appreciate that the number of mental health inpatient beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an inpatient admission being necessary. I also recognise that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.”

Source location

Response from Department of Health and Social care
Page 1 · response
Published 28 July 2026

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

Local ICBs and authorities are responsible for arranging crisis house provision and addressing concerns about specific facilities.

Verbatim wording from the response

“Local integrated care boards (ICBs) and commissioning partners such as local authorities have flexibility to decide how to arrange the provision of crisis houses and similar facilities in their local area. However, in providing this flexibility, we expect crisis house services to be designed in a way which aligns with national requirements and guidance and local structures, to ensure appropriate safeguarding processes are in place.”

Source location

Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026

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.2

  1. 1

    Deliver community mental health care through new models of care and support where appropriate.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
  2. 2

    Open new mental health crisis centres using £26 million in committed capital investment.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.

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

Deliver community mental health care through new models of care and support where appropriate.

Verbatim wording from the response

“Finally, turning to your concerns around long waiting times to access a psychological assessment, it is unacceptable that too many people are not receiving the mental health care they need when they need it and we know that waits for mental health services are far too long. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that is where when people need it, we will make sure that mental health care is delivered in the community where appropriate, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. We will also recruit an additional 8,500 mental health workers to cut waiting times and provide faster treatment which will also help ease pressure on busy mental health services. These new workers will be specially trained to support people at risk of suicide.”

Source location

Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026

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

Open new mental health crisis centres using £26 million in committed capital investment.

Verbatim wording from the response

“Turning to the role of crisis houses, these play an important role in local crisis response systems by reducing the demands on busy emergency mental health services, allowing them to deal with the most serious cases. They also provide a more familiar and therapeutic alternative to a clinical hospital setting for people who are experiencing distress or crisis. In the Autumn Budget 2024 we committed £26 million in capital investment to open new mental health crisis centres to reduce the pressure on busy A&E services and ensure more people get the support they need when they need it.”

Source location

Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026

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