PFD report

Wayne Pierce Walton · Prevention of Future Deaths report

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Issued 16 Jan 2026•Coventry

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
4

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.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to adequately complete risk assessment and risk formulation documentation
  2. Lack of guidance for managing conflicts of interest when staff or shadowing persons know a patient outside a personal relationship
  3. Lack of staff awareness of Home Treatment Team policies and required risk information
    Part of recurring concern: Unreliable community Home Treatment Team care pathways
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.6

  1. Action

    Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.

    Stated by NHS Coventry and Warwickshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
  2. Action

    Implement iterative refinements to EPR documentation templates and workflows using post-launch feedback.

    Stated by NHS Coventry and Warwickshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
  3. Action

    Introduce an addendum to the Personal Relationships at Work policy governing non-personal prior acquaintance between staff and patients.

    Stated by NHS Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.

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

  1. Position

    Existing discharge planning policies, oversight, crisis-team involvement and structured audit are considered sufficient to support safe, effective discharges.

    Stated by NHS Coventry and Warwickshire NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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 adequately complete risk assessment and risk formulation documentation

Wider context from the report

“(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. ”

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

Lack of guidance for managing conflicts of interest when staff or shadowing persons know a patient outside a personal relationship

Wider context from the report

“(2)There is in existence, a policy entitled “Personal Relationships at Work” which addresses personal relationships of a particular type, but which does not address the potential for a conflict of interest when a member of staff, or a person shadowing a member of staff, recognises that they may know a patient other than because of a personal relationship as envisaged in the aforementioned policy. The absence of guidance on how to manage this situation, may place both the member of staff and the patient at risk of harm. ”

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

Lack of staff awareness of Home Treatment Team policies and required risk information

Wider context from the report

“(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. ”

Is this part of a recurring concern?

Yes — Unreliable community Home Treatment Team care pathways.

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 pass important risk information to the Home Treatment Team

Wider context from the report

“(1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication within and between community mental-health teams; Unreliable community Home Treatment Team care pathways; Unreliable handover of care information and responsibility.

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

Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.

Verbatim wording from the response

“Our investigatory work from the Patient Safety Incident Investigation (PSII) report PSII2172, focused on learning and improvement, ensuring staff are supported to understand the processes to embed effective documentation of a person’s risk, as well as Trust processes to support safe discharge and/or transition between services. We are revising our Standard Operating Procedure (SOP) for Internal Transfers within Adult and Older Adults Mental Health Services (version 5), to reflect the function and structure of the new Electronic Patient Record (EPR) system (SystemOne), and provide clearer guidance on the agreed date of handover of care, the continuation and ownership of care packages during transfer, and the requirement for a joint handover meeting between teams, with an agreed date understood by all.”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 1 · response
Published 21 January 2026

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 iterative refinements to EPR documentation templates and workflows using post-launch feedback.

Verbatim wording from the response

“To ensure the system is delivering the intended quality and safety benefits, our next steps, following the EPR launch, are to:”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

Introduce an addendum to the Personal Relationships at Work policy governing non-personal prior acquaintance between staff and patients.

Verbatim wording from the response

“The Trust has introduced an addendum to strengthen existing governance arrangements and provide clearer guidance for staff (Appendix 3), included as an appendix to the existing Personal Relationships at Work policy. It introduces a clear process for managing situations in which staff recognise patients through non-personal prior acquaintance, such as community links, former workplaces, school settings, or casual social connections and aims to support in ensuring professional boundaries are maintained and care remains impartial, safe, and centred on the patient’s best interests.”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 3 · response
Published 21 January 2026

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

Launch the updated EPR Risk and Safety section with demonstration and quick-reference materials for staff.

Verbatim wording from the response

“As part of this work, the Trust has launched the updated Risk and Safety section within the EPR, supported by a demonstration package and quick reference guide to assist staff in embedding the new approach into practice. This enhancement strengthens clinical safety, improves the quality of documentation, and aligns practice to national guidance.”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

Repeat the clinical risk documentation audit to assess alignment with Staying Safe guidance and the new EPR system's impact.

Verbatim wording from the response

“To ensure the system is delivering the intended quality and safety benefits, our next steps, following the EPR launch, are to:”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.

Verbatim wording from the response

“Once ratified, we shall audit our internal transfers between teams to assess compliance, as well as any further opportunities to gain experience, on an ongoing basis.”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

Existing discharge planning policies, oversight, crisis-team involvement and structured audit are considered sufficient to support safe, effective discharges.

Verbatim wording from the response

“Discharge Planning The Trust has a clear and well-governed framework in place, to support the safe and effective discharge of patients from its inpatient mental health services. Discharge planning commences on admission and is overseen through regular multi-disciplinary team (MDT) review, with crisis teams routinely involved to support early identification of needs and safe transition. The process is guided by the Trust’s Discharge from Inpatient Mental Health Wards SOP (V1.1, February 2025) and the Trust’s Bed Management Policy, which set out defined responsibilities, standards, and safety requirements, to ensure consistency across all wards.”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

    Collect, analyse and report patient and staff feedback on safety-planning involvement, confidence and usability.

    Stated by NHS Coventry and Warwickshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
  2. 2

    Introduce a structured discharge-planning audit covering documentation, safety planning and patient and carer involvement.

    Stated by NHS Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  3. 3

    Participate in national collaboration work to co-produce personalised inpatient safety planning informed by evidence, guidance and lived experience.

    Stated by NHS Coventry and Warwickshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.

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

Collect, analyse and report patient and staff feedback on safety-planning involvement, confidence and usability.

Verbatim wording from the response

“To ensure the system is delivering the intended quality and safety benefits, our next steps, following the EPR launch, are to:”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

Introduce a structured discharge-planning audit covering documentation, safety planning and patient and carer involvement.

Verbatim wording from the response

“The Trust systematically reviews patient and carer feedback and incidents which staff report, to support monitoring the quality of discharge planning and application. A structured audit, aligned to the Discharge from Inpatient Mental Health Wards SOP, has been introduced to provide additional assurance regarding the quality of documentation, safety planning, and involvement of patients and their families or carers (Appendix 2). Collectively, these arrangements ensure safe, effective, and well-governed processes in place to support safe discharges.”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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

Participate in national collaboration work to co-produce personalised inpatient safety planning informed by evidence, guidance and lived experience.

Verbatim wording from the response

“Clinical Risk Assessment The Trust is one of ten organisations nationally participating in the National Collaboration Centre for Mental Health programme, supported by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and led by NHS England (November 2024 to March 2026). This programme focuses on the co-production of personalised inpatient safety planning, ensuring our local approach is shaped by national evidence, expert guidance, and the lived experience of patients and carers (Appendix 1).”

Source location

2026-0028 - Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 21 January 2026

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