PFD report

Jonathan James LANDER · Prevention of Future Deaths report

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Issued 18 Mar 2016•Worcestershire

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
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. Failure of governance procedures to ensure action plans are followed through
    Part of recurring concern: Failure to implement identified safety actions
  2. Lack of follow-up procedures for individuals discharged from one service to another
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
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.1

  1. Action

    Establish an embedded lessons database containing Root Cause Analysis action plans and completion evidence, with Governance Team monitoring.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2016.

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 governance procedures to ensure action plans are followed through

Wider context from the report

“(1) That there is not in place any policy or procedure for the following up of individuals who are seen by one service and thereafter discharged to another service. In the course of the inquest I was provided with a Root Cause Analysis which identified the failing mentioned above and which contained an action plan indicating that such a policy/procedure was to be implemented by September 2015. I was told in the course of the inquest that that policy/procedure has not been implemented. I was left with the sense that this is still to be considered but there appears to be no sense of urgency. I was further told that the Trust has a governance procedure to ensure that action plans are “followed through” but it seems to be clearly the case that this has not worked either. I respectfully suggest that you consider urgently the necessity for such a procedure / policy and to implement it. (2) (3) ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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

Lack of follow-up procedures for individuals discharged from one service to another

Wider context from the report

“(1) That there is not in place any policy or procedure for the following up of individuals who are seen by one service and thereafter discharged to another service. In the course of the inquest I was provided with a Root Cause Analysis which identified the failing mentioned above and which contained an action plan indicating that such a policy/procedure was to be implemented by September 2015. I was told in the course of the inquest that that policy/procedure has not been implemented. I was left with the sense that this is still to be considered but there appears to be no sense of urgency. I was further told that the Trust has a governance procedure to ensure that action plans are “followed through” but it seems to be clearly the case that this has not worked either. I respectfully suggest that you consider urgently the necessity for such a procedure / policy and to implement it. (2) (3) ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge.

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 an embedded lessons database containing Root Cause Analysis action plans and completion evidence, with Governance Team monitoring.

Verbatim wording from the response

“I can advise in relation to a governance procedure to implement the Action Plans set out in individual Root Cause Analyses that the Trust now has an Embedded Lessons Database. All the Action Plans set out in individual Root Cause Analyses are now uploaded to that database together with evidence of completed actions. This database is monitored by the Governance Team based in the Adult Mental Health and Learning Disability Service Delivery Unit.”

Source location

J-Lander-Response
Page 1 · response
Published 18 March 2016

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

    Implement and maintain a substance misuse information-sharing protocol with Swanswell to share relevant clinical information where mental health and substance misuse concerns arise.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2016.

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

Implement and maintain a substance misuse information-sharing protocol with Swanswell to share relevant clinical information where mental health and substance misuse concerns arise.

Verbatim wording from the response

“Following the request the Trust now has in place an agreed Substance Misuse Information Sharing Protocol between itself and Swanswell, Worcestershire Recovery Partnership. I enclose a copy for your ease of reference. The purpose of the protocol is to ensure relevant clinical and other material information is shared where there are concerns regarding a patient’s mental health and substance misuse, to ensure that services have up to date information and that patients will receive the appropriate treatment from both agencies.”

Source location

J-Lander-Response
Page 1 · response
Published 18 March 2016

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