PFD report

Lindsey Bailey · Prevention of Future Deaths report

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Issued 18 Jul 2019•Staffordshire South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised1

  1. Failure to share relevant information with consenting parents
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.2

  1. Action

    Develop and implement a standard family and carer letter template within mental health pathway assessment procedures.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.
  2. Action

    Develop and roll out a Crisis Response Home Treatment Carer Engagement Standard Operating Procedure across mental health pathways.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.

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

  1. Position

    Patient confidentiality and her expressed wish not to share all information limited the extent of family involvement.

    Stated by Midlands Partnership University 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 share relevant information with consenting parents

Wider context from the report

“At relevant times Ms Bailey did have mental capacity and was in agreement with information being shared with her parents. Reference was made to the Care Engagement Charter promulgated by the Trust. Despite this it appears that there was a significant lack in relevant information being shared with Ms Bailey’s parents. While this may not have necessarily have prevented the death it could have assisted in the treatment path and certainly may be relevant in other cases. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 implement a standard family and carer letter template within mental health pathway assessment procedures.

Verbatim wording from the response

“1) To develop a standard letter template which is sent out to families and carers whose family member have agreed for contact to be made. The letter will form part of our Standard Operating Procedures for assessment across our Mental Health Pathways and each letter will be modified to reflect the individual needs of the patient and their family member.”

Source location

2019-0235-Response-by-Midland-Partnership-NHS-Trust
Page 2 · response
Published 13 September 2019

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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 roll out a Crisis Response Home Treatment Carer Engagement Standard Operating Procedure across mental health pathways.

Verbatim wording from the response

“2) As part of the work to improve Carer Engagement the Trust is in the process of developing a Carer Engagement Standard Operating Procedure for Crisis Response Home Treatment Services which details the standards expected in respect of holding conversations with patients around family and carer involvement at first contact, and this then to be re-visited at every future appointment with the patient to ensure opportunities are not missed. Once developed this will be rolled out across all”

Source location

2019-0235-Response-by-Midland-Partnership-NHS-Trust
Page 2 · response
Published 13 September 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

Patient confidentiality and her expressed wish not to share all information limited the extent of family involvement.

Verbatim wording from the response

“We have considered carefully the difference between confidentiality whilst a patient has capacity versus the engagement of families or carers where the patient has declined for their information to be shared. We acknowledge that as a Trust we need to ensure all our staff are actively embedding family involvement within their daily practice whilst maintaining confidentiality. Whilst carer / family involvement (including gaining informed consent to share information with families) is written into all of our Standard Operating Procedures for assessment, we have identified that clear guidance and advice in engaging with families where the patient has declined for information to be shared is required.”

Source location

2019-0235-Response-by-Midland-Partnership-NHS-Trust
Page 1 · response
Published 13 September 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.2

  1. 1

    Develop and deliver an organisation-wide face-to-face and e-learning training programme on engaging families and carers.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.
  2. 2

    Monitor these actions through the Performance Plus tracking system, local governance meetings and escalation to the Quality Governance Sub-committee where appropriate.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.

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 deliver an organisation-wide face-to-face and e-learning training programme on engaging families and carers.

Verbatim wording from the response

“3) A bespoke training programme to be introduced to staff around engaging with families and carers. The programme is currently be developed and led by our Involvement and Experience Team. A Steering Group has been established, first meeting on 23rd August 2019, with service users and carers to plan for workshops that will be held in October to design and develop the training package. This will be delivered via face-to-face training for teams but also as an e-learning package. We plan to involve carer leads in the organisation, external carers’ organisations, Information Management and Technology, Quality Improvement Team and the Information Governance Team. Once the workshops are complete, we plan to roll the training out from 1st January 2020 onwards organisation-wide.”

Source location

2019-0235-Response-by-Midland-Partnership-NHS-Trust
Page 3 · response
Published 13 September 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

Monitor these actions through the Performance Plus tracking system, local governance meetings and escalation to the Quality Governance Sub-committee where appropriate.

Verbatim wording from the response

“4) All these actions will be monitored through the Performance Plus electronic action tracking system and will be discussed at local Governance team meetings and where appropriate escalated to the monthly Quality Governance Sub-committee.”

Source location

2019-0235-Response-by-Midland-Partnership-NHS-Trust
Page 3 · response
Published 13 September 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