PFD report

Terri Ann Malone · Prevention of Future Deaths report

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Issued 24 Oct 2022•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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised3

  1. Failure to establish current circumstances and input from other agencies before discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Discharge of service users after missed appointments without adequate follow-up
    Part of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
  3. Failure to involve an experienced practitioner directly in treatment-plan decisions
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

    Require trainees to discuss every assessment with a Senior Wellbeing Practitioner, obtain decision sign-off and escalate unresolved issues.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The service considered communication with other agencies unnecessary because no clinical reason or significant mental-health risk indicated information sharing.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustNo action considered necessaryThe respondent said that 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 establish current circumstances and input from other agencies before discharge

Wider context from the report

“(3) A decision is made to discharge the patient without establishing their current circumstances and the current (if any) input from other agencies; full details of whom and consent to share information could be obtained during initial instructions taken by a more experience practitioner. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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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

Discharge of service users after missed appointments without adequate follow-up

Wider context from the report

“(2) Notwithstanding the above a service user is discharged from the service if they fail to attend an appointment and do not respond to a voicemail by the end of the day. This despite the patient being required to wait several months for an appointment. ”

Is this part of a recurring concern?

Yes — Unreliable arrangement and communication of patient appointments and follow-up.

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 involve an experienced practitioner directly in treatment-plan decisions

Wider context from the report

“(1) Initial contact with the service is with an inexperienced practitioner and a decision is made regarding a treatment plan without any direct contact being made by an experienced practitioner. ”

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

Require trainees to discuss every assessment with a Senior Wellbeing Practitioner, obtain decision sign-off and escalate unresolved issues.

Verbatim wording from the response

“Every trainee practitioner has to discuss every assessment they complete, with the Senior Wellbeing Practitioner signing off their decisions, with an escalation process in place for any issues not resolved through the supervision process. Our approach is in line with other IAPT services across the country.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023

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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

The service considered communication with other agencies unnecessary because no clinical reason or significant mental-health risk indicated information sharing.

Verbatim wording from the response

“I appreciate your concerns that the service did not communicate with others involved with the patient, however, our clinical view was that was not necessary. The Healthy Minds team were aware of the assessment from the NMHT that there were no significant mental health needs identified and that she was continuing to engage with Turning Point. Discussion about information sharing and confidentiality is discussed in all initial assessments, although due to the nature of the service, where the majority of referrals to Healthy Minds are self referrals, the service is reliant on the patient disclosing any other external services with whom they are in contact. If necessary information proportionate to the risk faced can be shared with other agencies, although there was no clinical reason to do so in the present instance.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023

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

Discharging a patient after a missed appointment was considered sufficient under IAPT policy, with contact attempts and re-referral information provided.

Verbatim wording from the response

“Finally, I recognise your concern that the patient was discharged when she did not attend her treatment appointment, however, I also note that our actions were in line with the service policy and national model for IAPT services. In order for IAPT therapy to be successful the patient must be motivated and ready to engage, unfortunately, at times whilst patients initially indicate that they wish to access IAPT support, this is not always sustained. The patient received details of the treatment appointment by letter and a SMS prior to the appointment time. Following her missing the appointment she received a call to her mobile phone asking her to contact the service if she wished to continue. She was also sent a detailed letter discharging her from the service, which provided information on how she could refer back into the service if she wished to do so.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023

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.3

  1. 1

    Discuss information sharing and confidentiality during every initial assessment.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  2. 2

    Apply the national IAPT model and practice guide, including its approach to supporting people with alcohol and drug misuse.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  3. 3

    Provide weekly supervision for trainee psychological wellbeing practitioners through Senior Wellbeing Practitioners, Service Leads and the Clinical Lead.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.

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

  1. 1

    The service considers Healthy Minds appropriate for the patient and the initial assessment and resulting actions appropriate.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Discuss information sharing and confidentiality during every initial assessment.

Verbatim wording from the response

“I appreciate your concerns that the service did not communicate with others involved with the patient, however, our clinical view was that was not necessary. The Healthy Minds team were aware of the assessment from the NMHT that there were no significant mental health needs identified and that she was continuing to engage with Turning Point. Discussion about information sharing and confidentiality is discussed in all initial assessments, although due to the nature of the service, where the majority of referrals to Healthy Minds are self referrals, the service is reliant on the patient disclosing any other external services with whom they are in contact. If necessary information proportionate to the risk faced can be shared with other agencies, although there was no clinical reason to do so in the present instance.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023

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

Apply the national IAPT model and practice guide, including its approach to supporting people with alcohol and drug misuse.

Verbatim wording from the response

“I am writing to respond to the Regulation 28 Report to Prevent Future Deaths which was addressed to ████████ Clinical Lead for Herefordshire and Worcestershire Healthy Minds. As Healthy Minds is a service delivered by this Trust I am responding on behalf of the Trust.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 1 · response
Published 9 January 2023

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 weekly supervision for trainee psychological wellbeing practitioners through Senior Wellbeing Practitioners, Service Leads and the Clinical Lead.

Verbatim wording from the response

“The manual also reflects the importance of in-service training ‘A key feature for the IAPT programme is the in-service training opportunity, Trainees have the advantage of being able to practice, daily, the required skills for the therapy they are being trained to deliver, with the people who are experiencing the relevant clinical problems.’ In addition, the model provides a highly prescriptive approach to clinical supervision, supplemented by the IAPT supervision guidance. In our service all trainee psychological wellbeing practitioners are supervised weekly by a Senior Wellbeing Practitioner, who themselves has weekly supervision with the Service Lead, who has weekly supervision with the Clinical Lead.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023

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 service considers Healthy Minds appropriate for the patient and the initial assessment and resulting actions appropriate.

Verbatim wording from the response

“In terms of whether Healthy Minds was the appropriate service for the patient, my clinical team consider it was appropriate. As indicated above, the IAPT model recognises that for some patients they will also have alcohol and addiction issues and this does not preclude them for receiving IAPT services. The patient was motivated, engaged with Turning Point and had reduced her alcohol intake, all positive indicators that IAPT services may be beneficial to her. From assessment there was going to be a 9 week wait for treatment, which would allow an opportunity to demonstrate that her alcohol usage hadn’t increased and become a problem again. There was no evidence of severe mental illness or risks identified at the time of assessment.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 9 January 2023

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