PFD report

Caroline Ann STAITE · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 14 Oct 2024•Herefordshire

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised3

  1. Insufficiently robust procedures for sifting patients for consideration by Mind
  2. Failure to return patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested
    Part of recurring concern: Unsafe coordination and continuity during mental health service transfers
  3. Lack of transparency and encouragement in the procedure for returning patients from Mind to Neighbourhood Mental Health Team 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.2

  1. Action

    Co-produce and ratify a Standard Operating Procedure defining the Community Mental Health Link Worker role and safe support arrangements.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024.
  2. Action

    Provide Link Workers with established access to Neighbourhood Mental Health duty staff, team managers, clinical leads and weekly multidisciplinary meetings for care and risk concerns.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.

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

Insufficiently robust procedures for sifting patients for consideration by Mind

Wider context from the report

“(1) The Neighbourhood Mental Health Team should ensure that their procedures are sufficiently robust regarding the sifting of patients for consideration by Mind. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Failure to return patients to Neighbourhood Mental Health Team care and discontinue Mind worker involvement when requested

Wider context from the report

“(3) If so requested by the Mind worker the patient should be returned to the care of the Neighbourhood Mental Health Team and the involvement of the Mind worker discontinued. ”

Is this part of a recurring concern?

Yes — Unsafe coordination and continuity during mental health service transfers.

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 transparency and encouragement in the procedure for returning patients from Mind to Neighbourhood Mental Health Team care

Wider context from the report

“(2) The procedure for the return of patients from Mind to the care of the Neighbourhood Mental Health Team should be transparent and encouraged if the Mind worker feels that is appropriate. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Co-produce and ratify a Standard Operating Procedure defining the Community Mental Health Link Worker role and safe support arrangements.

Verbatim wording from the response

“Action: Since this time our Community Service Manager, Diane Topham, who oversees our Neighbourhood Mental Health Team has worked closely with the Herefordshire MIND service to co-produce a Standard Operating Procedure (SOP) for the community Mental Health Link Worker Service in Herefordshire.”

Source location

2024-0548 - Response from Herefordshire & Worcestershire NHS
Page 1 · response
Published 14 October 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

Provide Link Workers with established access to Neighbourhood Mental Health duty staff, team managers, clinical leads and weekly multidisciplinary meetings for care and risk concerns.

Verbatim wording from the response

“Action: The MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’ (registered professional) or Team Manager/ Clinical Lead, where they can identify any areas of concern with care and treatment plans.”

Source location

2024-0548 - Response from Herefordshire & Worcestershire NHS
Page 2 · response
Published 14 October 2024

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
1/1

Data last updated 7 September 2026