PFD report

Christopher James MORGAN · Prevention of Future Deaths report

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Issued 22 Oct 2013•North and East Cambridgeshire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Lack of clear policy on staff-to-patient ratios for escorted leave from psychiatric wards
    Part of recurring concern: Unreliable mental-health patient leave arrangementsPart of recurring concern: Unsafe management of inpatient leave and absence
  2. Failure to communicate with all relevant parties before changes in identified risk level
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 clear policy on staff-to-patient ratios for escorted leave from psychiatric wards

Wider context from the report

“The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards ”

Is this part of a recurring concern?

Yes — Unreliable mental-health patient leave arrangements; Unsafe management of inpatient leave and absence.

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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 to communicate with all relevant parties before changes in identified risk level

Wider context from the report

“That before any change in identified level of risk is decided upon, particularly in relation to access to leave, there is communication with all relevant parties concerned including family and carers to elicit their views. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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