Joan Hoggett · Prevention of Future Deaths report

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Issued 12 May 2022•Sunderland

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

Described in responses

Recipients and published responses

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 raised4

  1. Insufficient staffing capacity to cover required engagement work
    Part of recurring concern: Insufficient staffing cover for mental health services during absences
  2. Failure to act upon information provided by the perpetrator’s family
  3. Failure to share relevant information with the perpetrator’s family

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Discuss family-engagement compliance in monthly clinical supervision and monitor it through monthly random case-file audits.

  2. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Complete caseload reviews to assess embedding of the Getting to Know You process and appropriate signposting or referral for carers’ assessments.

  3. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Increase staff time available for service users and carers through Quality Priority 3 patient-care improvement work.

  4. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Engage stakeholders in further improvement work addressing use of the Getting to Know You documentation.

  5. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Share caseload-review findings and resulting actions across EIP, business-unit and locality meetings through the Trust-wide EIP steering group.

  6. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Review use of the Getting to Know You documentation to measure and further embed the process.

  7. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Implement improved carer information leaflets and a carer-specific electronic care-record folder capturing carers’ needs and support plans.

  8. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

    Develop a documentation checklist to guide accurate, consent-compliant Getting to Know You records within service users’ care.

  9. Department of Health and Social Care

    Increase the NHS mental health workforce to expand service capacity and support safer care delivery.

  10. Department of Health and Social Care

    Invest at least £2.3 billion annually to expand and transform NHS mental health services and increase treatment capacity.

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

  1. Department of Health and Social Care

    Responsibility for hospital staffing and operations lies with the relevant NHS Trust.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Insufficient staffing capacity to cover required engagement work

Wider context from the report

“1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of: - sharing information with them; and - acting upon information provided by them. I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue. 2. A more proactive approach may have been appropriate. I am concerned that the opportunities to engage more were not taken. Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others. ”

Is this part of a recurring concern?

Yes — Insufficient staffing cover for mental health services during absences.

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 act upon information provided by the perpetrator’s family

Wider context from the report

“1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of: - sharing information with them; and - acting upon information provided by them. I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue. 2. A more proactive approach may have been appropriate. I am concerned that the opportunities to engage more were not taken. Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others. ”

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 share relevant information with the perpetrator’s family

Wider context from the report

“1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of: - sharing information with them; and - acting upon information provided by them. I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue. 2. A more proactive approach may have been appropriate. I am concerned that the opportunities to engage more were not taken. Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others. ”

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 take available opportunities for proactive engagement with the perpetrator

Wider context from the report

“1. The family of the perpetrator were not as engaged by the Trust as much as they could have been in terms of: - sharing information with them; and - acting upon information provided by them. I acknowledge that this must take into account the Service User’s capacity and consent and also respecting confidentiality, but in this case these matters did not seem to be an issue. 2. A more proactive approach may have been appropriate. I am concerned that the opportunities to engage more were not taken. Engagement with the perpetrator was influenced to some extent by the capacity of the Mental Health Trust and its personnel to meet the competing demands of the Service with the resources at their disposal. This was more challenging at times of staff absence and the ability of the Trust to sufficiently cover the work needed with the perpetrator and others. ”

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

Discuss family-engagement compliance in monthly clinical supervision and monitor it through monthly random case-file audits.

Verbatim wording from the response

“This issue is also now routinely discussed with staff as part of clinical supervision each month and compliance is monitored during the monthly random audit of caselfiles, the results of which are showing good compliance. The EIP service has also developed a documentation checklist for staff to refer to as a guide to ensure that the GTKY documentation is accurate and central to a service user’s care, within the parameters of consent and confidentiality.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Complete caseload reviews to assess embedding of the Getting to Know You process and appropriate signposting or referral for carers’ assessments.

Verbatim wording from the response

“Since the above recommendation was made, the Trust has completed a number of caseload reviews to seek assurance that the GTKY process has been fully embedded into clinical practice and that carers are being signposted and referred for carers’ assessments as appropriate. This ensures that staff are proactively engaging with family members/carers in the provision of a service user’s care. The findings and actions following these caseload reviews have been shared across the EIP Team, Central Business Unit and locality meetings via the Trust-wide EIP steering group.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Increase staff time available for service users and carers through Quality Priority 3 patient-care improvement work.

Verbatim wording from the response

“The Trust is planning further improvement work in 2022/23 through their delivery of Quality Priority 3: Patient Care, which will increase the time staff are able to spend with service users and carers. This will include engagement with stakeholders and reviews to measure the use of the Getting to Know You documentation. This work has been delayed due to the Covid19 pandemic however, as acknowledged in the final Niche investigation report (published on 29 June 2022), this issue as a whole has been significantly progressed.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Engage stakeholders in further improvement work addressing use of the Getting to Know You documentation.

Verbatim wording from the response

“The Trust is planning further improvement work in 2022/23 through their delivery of Quality Priority 3: Patient Care, which will increase the time staff are able to spend with service users and carers. This will include engagement with stakeholders and reviews to measure the use of the Getting to Know You documentation. This work has been delayed due to the Covid19 pandemic however, as acknowledged in the final Niche investigation report (published on 29 June 2022), this issue as a whole has been significantly progressed.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Share caseload-review findings and resulting actions across EIP, business-unit and locality meetings through the Trust-wide EIP steering group.

Verbatim wording from the response

“Since the above recommendation was made, the Trust has completed a number of caseload reviews to seek assurance that the GTKY process has been fully embedded into clinical practice and that carers are being signposted and referred for carers’ assessments as appropriate. This ensures that staff are proactively engaging with family members/carers in the provision of a service user’s care. The findings and actions following these caseload reviews have been shared across the EIP Team, Central Business Unit and locality meetings via the Trust-wide EIP steering group.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Review use of the Getting to Know You documentation to measure and further embed the process.

Verbatim wording from the response

“The Trust is planning further improvement work in 2022/23 through their delivery of Quality Priority 3: Patient Care, which will increase the time staff are able to spend with service users and carers. This will include engagement with stakeholders and reviews to measure the use of the Getting to Know You documentation. This work has been delayed due to the Covid19 pandemic however, as acknowledged in the final Niche investigation report (published on 29 June 2022), this issue as a whole has been significantly progressed.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Implement improved carer information leaflets and a carer-specific electronic care-record folder capturing carers’ needs and support plans.

Verbatim wording from the response

“By way of background, the ‘Getting to know you’ (GTKY) process is designed to support staff to get to know the whole family of the person being cared for. By applying a ‘Think Family’ approach our staff aim to gain a better understanding of the patient’s background and family circumstances as well as identifying more quickly the patient’s main carer(s). Within a few days of coming into contact with Trust services, a member of staff is expected to arrange to spend some time with the carer/family member, to get to know them. The GTKY process was reviewed in 2018 in collaboration with carers. The outcome of the review led to the design of improved information leaflets and a new carer specific folder within the Electronic Care Record which will capture the needs of carers and record a plan on who best to support their needs.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Develop a documentation checklist to guide accurate, consent-compliant Getting to Know You records within service users’ care.

Verbatim wording from the response

“This issue is also now routinely discussed with staff as part of clinical supervision each month and compliance is monitored during the monthly random audit of caselfiles, the results of which are showing good compliance. The EIP service has also developed a documentation checklist for staff to refer to as a guide to ensure that the GTKY documentation is accurate and central to a service user’s care, within the parameters of consent and confidentiality.”

Source location

Response from CNTW NHS
Page 2 · response
Published 17 May 2022

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

Increase the NHS mental health workforce to expand service capacity and support safer care delivery.

Verbatim wording from the response

“You may wish to know that the mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared to December 2020, and by over 11,800 compared to December 2010. We know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services. Our aim, as set out in the Mental Health Implementation Plan, is to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 17 May 2022

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

Invest at least £2.3 billion annually to expand and transform NHS mental health services and increase treatment capacity.

Verbatim wording from the response

“To enable this increase in workforce, through the NHS Long Term Plan, we are investing at least £2.3 billion additional funding a year from 2019/20 to expand and transform mental health services in England by 2023/24. This will enable an extra two million people to be treated by NHS mental health services by 2023/24. This includes new integrated community models for adults with severe”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 17 May 2022

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

Responsibility for hospital staffing and operations lies with the relevant NHS Trust.

Verbatim wording from the response

“You raised concerns about the capacity of the Mental Health Trust, and its workforce, to engage with the perpetrator and to meet the competing demands of the service within the resources at its disposal. Responsibility for the staffing and operations of a hospital lies with the relevant Trust. However, the Department does recognise the need to increase capacity in NHS mental health services due to the increasing demand for services.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 17 May 2022

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