Ozan Cem ATASOY · Prevention of Future Deaths report

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Issued 9 Apr 2014•Hertfordshire

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
0

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised0

    Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

    1. Care Quality Commission

      Test the new mental health inspection methodology through Wave 1 inspections.

    2. Care Quality Commission

      Feed lessons from Wave 1 inspections into Wave 2 inspections.

    3. Care Quality Commission

      Incorporate the report’s contents into key lines of enquiry for the revised mental health inspection approach.

    4. Care Quality Commission

      Appoint Chief and Deputy Chief Inspectors of Hospitals, including a Deputy Chief Inspector with responsibility for mental health services.

    5. Care Quality Commission

      Publish the specialised approach to inspecting mental health services across NHS and independent sectors.

    6. Care Quality Commission

      Work with key partners in developing the Mental Health Crisis Care Concordat.

    7. Care Quality Commission

      Work with partners to develop better intelligence, shared learning and preventative action concerning mental health-related deaths.

    8. Care Quality Commission

      Disseminate the report’s issues within CQC and incorporate them into intelligence monitoring for future inspections.

    9. Care Quality Commission

      Include information about deaths in psychiatric detention in all future annual reports.

    10. Care Quality Commission

      Develop and use standard key lines of enquiry for inspections of mental health trusts.

    11. Care Quality Commission

      Deliver a thematic programme on the experiences and outcomes of people experiencing mental health crisis and publish a national report.

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

    1. Care Quality Commission

      The regulator does not prescribe specific staffing numbers or staff-patient ratios, assessing instead whether properly skilled staff meet patients’ needs.

      Outside remitThe respondent said that this matter was outside its role or authority.

    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

    Test the new mental health inspection methodology through Wave 1 inspections.

    Verbatim wording from the response

    “It is also hoped that the changes will help improve our identification of poor mental health care and point to interventions when things need to be put right. We have been testing out our new methodology with “Wave 1” inspections of NHS mental health trusts occurring during and the last financial year. We have learnt lessons from those inspections which are now being fed into “Wave 2” inspections to ensure our regulatory responses are robust, proportionate and sustainable.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 2 · response
    Published 9 April 2014

    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

    Feed lessons from Wave 1 inspections into Wave 2 inspections.

    Verbatim wording from the response

    “It is also hoped that the changes will help improve our identification of poor mental health care and point to interventions when things need to be put right. We have been testing out our new methodology with “Wave 1” inspections of NHS mental health trusts occurring during and the last financial year. We have learnt lessons from those inspections which are now being fed into “Wave 2” inspections to ensure our regulatory responses are robust, proportionate and sustainable.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 2 · response
    Published 9 April 2014

    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

    Incorporate the report’s contents into key lines of enquiry for the revised mental health inspection approach.

    Verbatim wording from the response

    “We confirm that the contents of your report, and the issues identified therein, will be disseminated within the CQC and in particular in relation to inspections of hospitals built in a similar way to Queen Elizabeth II Hospital. The issues will be fed into the intelligence monitoring systems that allow us to monitor services and also to plan and carry out future inspections. It is intended that the contents of your report in this case will form evidence that will be fed into the key lines of enquiry that form the core of our revised approach to the monitoring and regulation of mental health services.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 1 · response
    Published 9 April 2014

    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

    Appoint Chief and Deputy Chief Inspectors of Hospitals, including a Deputy Chief Inspector with responsibility for mental health services.

    Verbatim wording from the response

    “• The appointment of new Chief and Deputy Chief Inspectors of Hospitals. This includes the appointment of ████████ ████████ as Deputy Chief Inspector of Hospitals with a portfolio of mental health services. It is hoped that those appointments will provide important specialist leadership for our regulatory and MHA monitoring roles.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 2 · response
    Published 9 April 2014

    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 the specialised approach to inspecting mental health services across NHS and independent sectors.

    Verbatim wording from the response

    “We have now published our intentions for a more specialised approach to the inspection of mental health services in both the NHS and independent sector. The”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 1 · response
    Published 9 April 2014

    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

    Work with key partners in developing the Mental Health Crisis Care Concordat.

    Verbatim wording from the response

    “We will work with partners, including NHS England and the National Confidential Inquiry into suicide and homicide by people with mental illness, to look at how we can do this in a way that offers better intelligence and opportunities for shared learning and preventative action. The Commission will also work with key partners in developing the Mental Health Crisis Care Concordat. This will focus attention on the issues that have been highlighted around emergency mental health care. The Commission has committed to delivering a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, and will take this forward over the rest of 2014 with the intention of publishing a national report in shortly in the autumn.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 3 · response
    Published 9 April 2014

    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

    Work with partners to develop better intelligence, shared learning and preventative action concerning mental health-related deaths.

    Verbatim wording from the response

    “We will work with partners, including NHS England and the National Confidential Inquiry into suicide and homicide by people with mental illness, to look at how we can do this in a way that offers better intelligence and opportunities for shared learning and preventative action. The Commission will also work with key partners in developing the Mental Health Crisis Care Concordat. This will focus attention on the issues that have been highlighted around emergency mental health care. The Commission has committed to delivering a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, and will take this forward over the rest of 2014 with the intention of publishing a national report in shortly in the autumn.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 3 · response
    Published 9 April 2014

    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

    Disseminate the report’s issues within CQC and incorporate them into intelligence monitoring for future inspections.

    Verbatim wording from the response

    “We confirm that the contents of your report, and the issues identified therein, will be disseminated within the CQC and in particular in relation to inspections of hospitals built in a similar way to Queen Elizabeth II Hospital. The issues will be fed into the intelligence monitoring systems that allow us to monitor services and also to plan and carry out future inspections. It is intended that the contents of your report in this case will form evidence that will be fed into the key lines of enquiry that form the core of our revised approach to the monitoring and regulation of mental health services.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 1 · response
    Published 9 April 2014

    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

    Include information about deaths in psychiatric detention in all future annual reports.

    Verbatim wording from the response

    “The Commission has also identified five key areas of action which we are confident will improve the identification and resolution of the sorts of issues that arose in this case. Those areas of action are in line with, and complement, our strategic intentions including recognising that people in the care of specialist mental health services are a high risk group for suicide and unidentified, poorly treated or preventable physical ill-health. We are concerned about how services respond to, review and report on deaths, so we are committing to include the information we hold on deaths in psychiatric detention in all future annual reports.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 3 · response
    Published 9 April 2014

    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 and use standard key lines of enquiry for inspections of mental health trusts.

    Verbatim wording from the response

    “As part of the new inspection methodology for specialist mental health services a set of standard key lines of enquiry (‘KLOEs’) have been developed for use in inspections of mental health trusts. It is intended that a standard set will also ensure consistency of what we look at under each domain, which is vital for reaching a credible comparative rating. By way of background the standard KLOEs are underpinned by a series of prompts. Those prompts will be considered to be a guide as to what to inspect in order to answer the KLOE. The main prompts addressing the sorts of issues raised in your report would be as follows:”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 3 · response
    Published 9 April 2014

    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

    Deliver a thematic programme on the experiences and outcomes of people experiencing mental health crisis and publish a national report.

    Verbatim wording from the response

    “We will work with partners, including NHS England and the National Confidential Inquiry into suicide and homicide by people with mental illness, to look at how we can do this in a way that offers better intelligence and opportunities for shared learning and preventative action. The Commission will also work with key partners in developing the Mental Health Crisis Care Concordat. This will focus attention on the issues that have been highlighted around emergency mental health care. The Commission has committed to delivering a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, and will take this forward over the rest of 2014 with the intention of publishing a national report in shortly in the autumn.”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 3 · response
    Published 9 April 2014

    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 regulator does not prescribe specific staffing numbers or staff-patient ratios, assessing instead whether properly skilled staff meet patients’ needs.

    Verbatim wording from the response

    “3. In relation to staffing levels, we do not prescribe the particular number of staff members that are being employed to meet patients’ needs, or particular staff-patient ratios. Rather, our assessment of whether essential standards of care are being met in this respect is based on considering the sufficiency of properly skilled staff to meet patients’ particular needs. The following proposed prompts would be most relevant to under the new methodology in assessing whether the provider ensures that staffing levels and quality of staffing enables safe practice:”

    Source location

    2014-0166-Response-by-Care-Quality-Commission_Redacted
    Page 4 · response
    Published 9 April 2014

    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