PFD report

Jonathan Alan Thorpe · Prevention of Future Deaths report

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Issued 7 Jan 2014•Manchester South

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

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

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Concerns raised1

  1. Failure to seek advice from or consider further input from Mental Health Services
    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 to seek advice from or consider further input from Mental Health Services

Wider context from the report

“The deceased registered with your GP practice on the 20th March 2013, was seen by ████████ on the 25th March and was issued a ‘sick note’ and was prescribed Amitriptyline for depression (despite being a known self-harmer). He was then seen on the 28th March by ████████ when a further ‘sick note’ was issued, this time back dated for one month. On neither of these consultations was there any reference to Mental Health Services, either for advice as to his previous involvement with them nor as to whether he needed further input from them. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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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