Christopher James MORGAN · Prevention of Future Deaths report

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Issued 22 Oct 2013•North and East Cambridgeshire

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.

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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

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. 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
No response statements

No respondent-stated action or position is included in the published responses for this 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 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.

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 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