PFD report

Mr Stuart Tokam · Prevention of Future Deaths report

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Issued 13 Aug 2021•East 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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
2

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 raised2

  1. Lack of a process to triage referral acuity and expedite clinical assessments where necessary
    Part of recurring concern: Failure to complete timely direct mental health assessments after referral
  2. Delays in arranging clinical assessments
    Part of recurring concern: Failure to complete timely direct mental health assessments after referral
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

Lack of a process to triage referral acuity and expedite clinical assessments where necessary

Wider context from the report

“2. There appears to have been no process in place to triage the acuity of a referral and expedite a clinical assessment where necessary. ”

Is this part of a recurring concern?

Yes — Failure to complete timely direct mental health assessments after referral.

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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

Delays in arranging clinical assessments

Wider context from the report

“1. There was an unacceptable delay in arranging a clinical assessment of Mr Tokam. ”

Is this part of a recurring concern?

Yes — Failure to complete timely direct mental health assessments after referral.

Open source report

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

    Provide targeted, ring-fenced funding to integrated care systems for suicide prevention, self-harm prevention and postvention bereavement support.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2021.
  2. 2

    Work with NHS England, NHS Improvement and the UK Health Security Agency to support local areas in delivering multi-agency suicide prevention plans.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Care Quality Commission will review the Trust’s response and decide whether any further action is required.

    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 respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide targeted, ring-fenced funding to integrated care systems for suicide prevention, self-harm prevention and postvention bereavement support.

Verbatim wording from the response

“As part of the £2.3billion settlement for mental health in the NHS Long Term Plan, the Department is providing targeted and ring-fenced funding to integrated care systems (ICS) so they can deliver their multi-agency plans. This includes suicide prevention activities, initiatives to prevent self-harm and putting in place postvention bereavement support.”

Source location

2021-0271-Response-from-DHSC_Published
Page 2 · response
Published 19 August 2021

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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

Work with NHS England, NHS Improvement and the UK Health Security Agency to support local areas in delivering multi-agency suicide prevention plans.

Verbatim wording from the response

“Reducing suicide and preventing self-harm remains a key priority for the Government and the Department is working closely with NHSE/I and UK Health Security Agency to support local areas to deliver multi-agency suicide prevention plans.”

Source location

2021-0271-Response-from-DHSC_Published
Page 2 · response
Published 19 August 2021

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 Care Quality Commission will review the Trust’s response and decide whether any further action is required.

Verbatim wording from the response

“You may wish to note that the Care Quality Commission, the independent regulator for quality, will review the Trust’s response to your report, as part of its ongoing monitoring, and consider whether any further action is required.”

Source location

2021-0271-Response-from-DHSC_Published
Page 1 · response
Published 19 August 2021

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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