PFD report

Lucy Ann THORNTON · Prevention of Future Deaths report

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Issued 27 Jan 2026•Hampshire, Portsmouth and Southampton

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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

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Concerns raised2

  1. Insufficient understanding of Category 1 response criteria for hanging incidents
    Part of recurring concern: Unreliable emergency-service incident grading and response-time coordinationPart of recurring concern: Unsafe emergency call handling
  2. Failure to telephone the person when relevant information is incomplete
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.4

  1. Action

    Deliver mandatory refresher training and updated materials on suicidal-patient call management, escalation, response categories, information gathering, and risk assessment.

    Stated by Isle of Wight NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
  2. Action

    Continue working with national bodies to strengthen guidance and NHS Pathways for risks involving suicidal patients and potential hanging.

    Stated by Isle of Wight NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
  3. Action

    Request national review of whether Category 1 disposition is appropriate for patients threatening to hang themselves.

    Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 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

    National NHS Pathways bodies are responsible for deciding whether Category 1 responses are appropriate for potential hanging incidents.

    Stated by Isle of Wight NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Insufficient understanding of Category 1 response criteria for hanging incidents

Wider context from the report

“The level of training and understanding of relevant call handling procedures and processes by those employed as call handlers in relation to incidents concerning hanging: 1 The procedures direct a Category 1 response (7 minutes) when the person has the means to suspend themselves and has stated that is there present intention. The call handler believes that a Category 1 response is, "When they are going to die now". 2 The procedures direct that when the call handler does not have all relevant information they should telephone the person and ask questions in relation to the person's present situation. The call handler was on the Isle of Wight. THORNTON was in Southsea. The call handler did not call THORNTON as she felt she was too remote (geographically). ”

Is this part of a recurring concern?

Yes — Unreliable emergency-service incident grading and response-time coordination; Unsafe emergency call handling.

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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 telephone the person when relevant information is incomplete

Wider context from the report

“The level of training and understanding of relevant call handling procedures and processes by those employed as call handlers in relation to incidents concerning hanging: 1 The procedures direct a Category 1 response (7 minutes) when the person has the means to suspend themselves and has stated that is there present intention. The call handler believes that a Category 1 response is, "When they are going to die now". 2 The procedures direct that when the call handler does not have all relevant information they should telephone the person and ask questions in relation to the person's present situation. The call handler was on the Isle of Wight. THORNTON was in Southsea. The call handler did not call THORNTON as she felt she was too remote (geographically). ”

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

Deliver mandatory refresher training and updated materials on suicidal-patient call management, escalation, response categories, information gathering, and risk assessment.

Verbatim wording from the response

“Additional training has been introduced for all call handlers to reinforce the appropriate management of calls involving suicidal patients.”

Source location

Response from Isle of Wight NHS Trust
Page 2 · response
Published 29 January 2026

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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

Continue working with national bodies to strengthen guidance and NHS Pathways for risks involving suicidal patients and potential hanging.

Verbatim wording from the response

“The Trust remains fully committed to learning from this incident and to strengthening its systems and processes to reduce the risk of similar occurrences in the future. We will continue to work with national bodies to ensure that guidance and NHS Pathways appropriately reflect the risks associated with suicidal patients, including those involving potential hanging.”

Source location

Response from Isle of Wight NHS Trust
Page 3 · response
Published 29 January 2026

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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

Request national review of whether Category 1 disposition is appropriate for patients threatening to hang themselves.

Verbatim wording from the response

“This incident and your Prevention of Future Deaths report will be formally reported to the national NHS Pathways group. It has also been raised at the National Heads of Emergency Operations Centre meeting, with a request that existing pathways be reviewed to consider whether a Category 1 disposition is appropriate in such circumstances.”

Source location

Response from Isle of Wight NHS Trust
Page 2 · response
Published 29 January 2026

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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

Amend guidance to require reasonable direct contact attempts with individuals at risk wherever they are located when information is incomplete.

Verbatim wording from the response

“Guidance has been amended and strengthened to make clear that where relevant information is incomplete, call handlers must make reasonable attempts to contact the individual directly, wherever they are located, in order to obtain information necessary for an accurate risk assessment.”

Source location

Response from Isle of Wight NHS Trust
Page 2 · response
Published 29 January 2026

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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

National NHS Pathways bodies are responsible for deciding whether Category 1 responses are appropriate for potential hanging incidents.

Verbatim wording from the response

“At present, there is no NHS Pathways outcome that results in a Category 1 response for a patient threatening to hang themselves, even where means are present. A Category 1 response is only triggered where a patient is actively in the process of hanging.”

Source location

Response from Isle of Wight NHS Trust
Page 2 · response
Published 29 January 2026

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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

    Maintain clinical validation and automated escalation processes for suicidal-patient calls.

    Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
  2. 2

    Issue direction requiring immediate escalation to a senior colleague when call handlers cannot manage calls because of personal sensitivity or other factors.

    Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
  3. 3

    Report the incident and Prevention of Future Deaths report to the national NHS Pathways group.

    Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 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

Maintain clinical validation and automated escalation processes for suicidal-patient calls.

Verbatim wording from the response

“Following a letter from Professor Jonathan Benger in April 2021 regarding clinical validation processes, the Association of Ambulance Chief Executives established a clinical validation process in October 2023 for patients threatening suicide, which has been adopted by the Isle of Wight Ambulance Service.”

Source location

Response from Isle of Wight NHS Trust
Page 2 · response
Published 29 January 2026

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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

Issue direction requiring immediate escalation to a senior colleague when call handlers cannot manage calls because of personal sensitivity or other factors.

Verbatim wording from the response

“In addition, clear direction has been issued to the call handling team regarding escalation procedures where a call handler feels unable to manage a call due to personal sensitivity or other factors. In such circumstances, the call must be escalated immediately to a senior colleague so that another member of the team can take over and ensure there is no delay in the patient pathway.”

Source location

Response from Isle of Wight NHS Trust
Page 3 · response
Published 29 January 2026

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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

Report the incident and Prevention of Future Deaths report to the national NHS Pathways group.

Verbatim wording from the response

“This incident and your Prevention of Future Deaths report will be formally reported to the national NHS Pathways group. It has also been raised at the National Heads of Emergency Operations Centre meeting, with a request that existing pathways be reviewed to consider whether a Category 1 disposition is appropriate in such circumstances.”

Source location

Response from Isle of Wight NHS Trust
Page 2 · response
Published 29 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