PFD report

John Michael KIRBY · Prevention of Future Deaths report

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Issued 6 Dec 2018•Brighton and Hove

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
11

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published 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.

Concerns raised11

  1. Failure to record the consultation about the impact of the ADHD diagnosis
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure to consider relevant substance use and suicide risk before prescribing Concerta
    Part of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable assessment of suicide and self-harm risk
  3. Failure to recognise and act on recorded information about suicidal intent
    Part of recurring concern: Failure to reliably escalate suicidal intent information
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.8

  1. Action

    Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.
  2. Action

    Co-manage all ADHD patients with the Neurobehavioural Team to provide ongoing monitoring.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.
  3. Action

    Share ADHD NICE guidance with all doctors through the Mediconnect intranet forum.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.

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

  1. Position

    The A&E attendance did not heighten concern because the presentation was previously seen with alcohol use and liaison staff did not recommend re-referral.

    Stated by Sussex Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 record the consultation about the impact of the ADHD diagnosis

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 consider relevant substance use and suicide risk before prescribing Concerta

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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 recognise and act on recorded information about suicidal intent

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

Is this part of a recurring concern?

Yes — Failure to reliably escalate suicidal intent information.

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 follow NICE guidance for ADHD management

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

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 properly monitor Concerta treatment

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

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

Inappropriate ADHD assessment and prescribing suggestion

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing; Unsafe reliance on clinical questionnaires during patient assessment.

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 inform the GP of the ADHD diagnosis

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

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

Delays in dealing with the patient

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

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

Prescribing Concerta without further clinical review

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 obtain sufficient details of a reported suicide attempt

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

Is this part of a recurring concern?

Yes — Failure to make previous self-harm and suicide-risk information available for safety assessments; Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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 discuss the ADHD diagnosis with the immediate next of kin

Wider context from the report

“(1) The delay in dealing with Mr Kirby between August 2017 and March 2018. (2) I am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta. (3) I am concerned that although ████████ told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with John when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. (4) On the last occasion when John was seen, ie. on March the 20th diagnosis of ADHD was discussed and ████████ decided not to prescribe Concerta. A few weeks later, in April, he received a letter from Mr Kirby’s GP explaining that John wanted to be prescribed Concerta and also saying that he had had an admission to A&E. This did not provoke any further review of Mr Kirby, he was simply prescribed the medication without any discussion as to his previous drug abuse or current dependence on Diazepam, suicidal tendencies or binge drinking. This is outwith the Guidance issued by NICE. (5) Why was Mr Kirby prescribed Concerta without any (further) review? (6) Why was he not properly monitored as he should have been had the NICE Guidance been adhered too? (7) Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4th-5th April should have alerted the Trust to the information John had given that he was suicidal and “wanted to die”. (8) Why did those interviewing John in A&E not take more details of the suicide attempt when he said that recently he had tried to hang himself and only failed because the rope broke? ”

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

Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.

Verbatim wording from the response

“As your concern centres on clinical decision-making I asked the Trust’s Chief Medical Officer ████████ to set up a group of senior medical colleagues to review ████████ medical practice in relation to ADHD. The terms of reference of that medical decision-making group (DMG) included consideration of the use of ADHD questionnaires for diagnosis as well as consideration of the assessment and diagnosis of ADHD and recommended prescribing.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 12 May 2019

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

Co-manage all ADHD patients with the Neurobehavioural Team to provide ongoing monitoring.

Verbatim wording from the response

“An immediate action that was taken was to ensure that all ████████ ADHD patients were co-managed with the Neurobehavioural Team. Additionally, a clinical review of all ADHD prescribing within the relevant team was completed which, I am pleased to say, did not identify any concerns.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 12 May 2019

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 ADHD NICE guidance with all doctors through the Mediconnect intranet forum.

Verbatim wording from the response

“In addition to the above, the DMG took a number of further steps to establish wider learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect which is our doctors’ intranet forum for highlighting items of importance/interest/learning etc. Additionally, the issues arising from this case are to be presented for learning and discussion at the Trust’s forthcoming Effective Care & Treatment Conference next month. Furthermore, we are to publish a story, based on this case and to specifically include the issues surrounding co-morbid substance misuse, in our Patient Safety Matters; this is an internal learning publication that we use to improve patient safety.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 4 · response
Published 12 May 2019

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

Obtain specialist review of ADHD practice and repeat training on NICE guidance and the local shared-care protocol.

Verbatim wording from the response

“An outcome of the DMG review was to seek assistance from Professor ████████ (Chair in Psychiatry, University of Sussex) who has agreed to review Mr Kirby’s case with ████████ on 25 March 2019 and recommend any training needs, focussing on using NICE guidance and local shared care protocol for ADHD cases.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 12 May 2019

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

Publish a Patient Safety Matters story covering the case and issues surrounding co-morbid substance misuse.

Verbatim wording from the response

“In addition to the above, the DMG took a number of further steps to establish wider learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect which is our doctors’ intranet forum for highlighting items of importance/interest/learning etc. Additionally, the issues arising from this case are to be presented for learning and discussion at the Trust’s forthcoming Effective Care & Treatment Conference next month. Furthermore, we are to publish a story, based on this case and to specifically include the issues surrounding co-morbid substance misuse, in our Patient Safety Matters; this is an internal learning publication that we use to improve patient safety.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 4 · response
Published 12 May 2019

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

Reduce the Lead Practitioner’s caseload and provide robust ongoing caseload review and supervision.

Verbatim wording from the response

“The recommended measures to address those failings involved establishing that Mr Kirby’s Lead Practitioner’s caseload was such that he had sufficient capacity to ensure an appropriate level of care was delivered and that there be greater oversight and management of his caseload. I confirm that those measures were and continue to be taken. Specifically, there has been a significant reduction in his caseload coupled with robust and ongoing review of that caseload and supervision to secure that he is fully supported to deliver the level of care that is expected.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 1 · response
Published 12 May 2019

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

Create an information-sharing protocol between the Mental Health Liaison Team and Pavillions A&E liaison service.

Verbatim wording from the response

“I am informed that the evidence at the Inquest showed that Mr Kirby provided the Pavillions A&E liaison nurse with this suicide attempt information but that our Mental Health Liaison nurse was not aware of it. As this has identified a gap in the working between the two services the manager responsible for our Mental Health Liaison Team has worked with her Pavillions counter-part to create an information sharing protocol”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 3 · response
Published 12 May 2019

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 a clinical review of ADHD prescribing within the relevant team.

Verbatim wording from the response

“An immediate action that was taken was to ensure that all ████████ ADHD patients were co-managed with the Neurobehavioural Team. Additionally, a clinical review of all ADHD prescribing within the relevant team was completed which, I am pleased to say, did not identify any concerns.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 12 May 2019

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 A&E attendance did not heighten concern because the presentation was previously seen with alcohol use and liaison staff did not recommend re-referral.

Verbatim wording from the response

“████████ informs me that he reviewed the details of Mr Kirby’s A&E admission upon receipt of the letter from the GP seeking the prescribing advice. His clinical opinion at that time was that Mr Kirby’s presentation at A&E was not new; that is to say that he had previously presented similarly when under the influence of alcohol. ████████ also took into account that Mr Kirby was assessed by the Mental Health Liaison Team who didn’t consider re-referring him. Therefore ████████ concern for Mr Kirby was not heightened by this attendance at A&E.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 3 · response
Published 12 May 2019

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.1

  1. 1

    Present the case’s issues for learning and discussion at the forthcoming Effective Care & Treatment Conference.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 May 2019.

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

  1. 1

    Practitioner Performance Advice was satisfied with the actions taken and identified no further action that ought to be taken.

    Stated by Sussex Partnership NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.

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

Present the case’s issues for learning and discussion at the forthcoming Effective Care & Treatment Conference.

Verbatim wording from the response

“In addition to the above, the DMG took a number of further steps to establish wider learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect which is our doctors’ intranet forum for highlighting items of importance/interest/learning etc. Additionally, the issues arising from this case are to be presented for learning and discussion at the Trust’s forthcoming Effective Care & Treatment Conference next month. Furthermore, we are to publish a story, based on this case and to specifically include the issues surrounding co-morbid substance misuse, in our Patient Safety Matters; this is an internal learning publication that we use to improve patient safety.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 4 · response
Published 12 May 2019

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

Practitioner Performance Advice was satisfied with the actions taken and identified no further action that ought to be taken.

Verbatim wording from the response

“Finally, I would like to assure you that ████████ shared your concerns and the actions we have taken with Practitioner Performance Advice (formerly NCAS) to ensure that there was no further action that they felt ought to be taken and I confirm that they were satisfied with our actions.”

Source location

2018-0379-Response-by-Sussex-NHS-Trust
Page 4 · response
Published 12 May 2019

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