PFD report

Jai · Prevention of Future Deaths report

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Issued 25 Nov 2024•Berkshire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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. Failure to provide a care co-ordinator or key worker after hospital discharge
    Part of recurring concern: Failure to provide continuity of patient care
  2. Failure of RiO and BTT teams to access each other’s clinical notes
    Part of recurring concern: Unreliable RIO clinical-record functions
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.2

  1. Action

    Establish effective BTT staff access to the Trust’s RiO electronic health records system through documented procedures.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
  2. Action

    Progress the Quality Improvement project to make care-transfer changes sustainable, Trust-wide and effective in mitigating recurrence risk.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.

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

  1. Position

    Direct secondary-care access to BTT records is not provided, but shared records and BTT’s established RiO access are considered sufficient.

    Stated by Oxford Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 a care co-ordinator or key worker after hospital discharge

Wider context from the report

“1. The Trust’s own internal investigation highlighted the fact that no care co-ordinator or key worker was provided to Jai after her discharge from hospital on 7th of September 2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s death. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of patient care.

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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

Failure of RiO and BTT teams to access each other’s clinical notes

Wider context from the report

“2. It is still not possible for teams using RiO and the BTT systems to access each other’s clinical notes. ”

Is this part of a recurring concern?

Yes — Unreliable RIO clinical-record functions.

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

Establish effective BTT staff access to the Trust’s RiO electronic health records system through documented procedures.

Verbatim wording from the response

“For their part, some BTT staff have direct access to RiO, which is the electronic health records system used by the Trust’s secondary care services. Those staff include the admin team, referral co-ordinators in SPA, and supervisors. BTT’s standard operating procedure records the procedure for BTT staff to do so. I understand that you have received a copy of that operating procedure. I am satisfied that BTT’s access to RiO is established and effective for their purposes.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 27 November 2024

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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

Progress the Quality Improvement project to make care-transfer changes sustainable, Trust-wide and effective in mitigating recurrence risk.

Verbatim wording from the response

“In relation to your first concern, I acknowledge that a delay in the completion of an action that arises from a patient safety incident investigation is a concern. I have asked to receive a report from the Oxford Healthcare Improvement Manager by the end of January 2025. In the meantime, I am satisfied that the Quality Improvement project has been progressing well. The purpose of this project is for us to ensure that the changes made are sustainable and Trust wide and that they do indeed mitigate against the risk of a similar event. I have been informed that a meeting takes place every fortnight in order to review progress (the most recent meeting was on 17th December 2024). The Trust is clear about the critical importance of the process by which a patient’s care is transferred from a ward to community teams.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 1 · response
Published 27 November 2024

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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

Direct secondary-care access to BTT records is not provided, but shared records and BTT’s established RiO access are considered sufficient.

Verbatim wording from the response

“I understand that your second concern relates to records held by Buckinghamshire Talking Therapies (BTT). It was the case that members of our secondary care services did not have access to those records in 2022 and 2023. That remains the case, in that staff in secondary care services cannot log into BTT’s electronic records system direct. The position is that”

Source location

Response from Oxford Health NHS Foundation Trust
Page 1 · response
Published 27 November 2024

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.4

  1. 1

    Maintain governance and audit scrutiny of the process for transferring patient care from wards to community teams.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.
  2. 2

    Upload BTT patient information to TVS Shared Care Records, including daily uploads for continuing BTT involvement unless patients opt out.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
  3. 3

    Update Intranet guidance on using Thames Valley & Surrey Shared Care Records.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
  4. 4

    Obtain a report on completion of the patient-safety action by the end of January 2025.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.

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

Maintain governance and audit scrutiny of the process for transferring patient care from wards to community teams.

Verbatim wording from the response

“It is a process that will always remain under scrutiny by Trust governance and audit.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 1 · response
Published 27 November 2024

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

Upload BTT patient information to TVS Shared Care Records, including daily uploads for continuing BTT involvement unless patients opt out.

Verbatim wording from the response

“secondary care services have access to a system called Thames Valley & Surrey (TVS) Shared Care Records/Graphnet, to which system BTT has uploaded patient information dating back to 1st May 2022. This upload concluded in November 2024. Subsequently, all patients accessing BTT will have information of their involvement with BTT uploaded on TVS each day (unless they have universally opted out of information sharing).”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 27 November 2024

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

Update Intranet guidance on using Thames Valley & Surrey Shared Care Records.

Verbatim wording from the response

“More generally, our Intranet contains guidance on the use of Thames Valley & Surrey Shared Care Records and this guidance was most recently updated on 12th December 2024.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 27 November 2024

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

Obtain a report on completion of the patient-safety action by the end of January 2025.

Verbatim wording from the response

“In relation to your first concern, I acknowledge that a delay in the completion of an action that arises from a patient safety incident investigation is a concern. I have asked to receive a report from the Oxford Healthcare Improvement Manager by the end of January 2025. In the meantime, I am satisfied that the Quality Improvement project has been progressing well. The purpose of this project is for us to ensure that the changes made are sustainable and Trust wide and that they do indeed mitigate against the risk of a similar event. I have been informed that a meeting takes place every fortnight in order to review progress (the most recent meeting was on 17th December 2024). The Trust is clear about the critical importance of the process by which a patient’s care is transferred from a ward to community teams.”

Source location

Response from Oxford Health NHS Foundation Trust
Page 1 · response
Published 27 November 2024

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