PFD report

Rebecca Louise Overy · Prevention of Future Deaths report

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Issued 17 Dec 2014•Nottinghamshire

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
2

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 raised2

  1. Lack of secure mental health care provision for young adults aged 18-24 with a similar clinical picture
    Part of recurring concern: Insufficient age-appropriate mental health provision for young people transitioning to adulthood
  2. Failure to ensure that immediate transfers at age 18 are in the person's best interests
    Part of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unsafe transition and continuity of care from child to adult healthcare
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.

    Stated by Department of Health and Social CareExisting 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

Lack of secure mental health care provision for young adults aged 18-24 with a similar clinical picture

Wider context from the report

“2. That there is no provision for secure mental health care for young adults in the age range 18-24, with a clinical picture similar to Rebecca’s. ”

Is this part of a recurring concern?

Yes — Insufficient age-appropriate mental health provision for young people transitioning to adulthood.

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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 ensure that immediate transfers at age 18 are in the person's best interests

Wider context from the report

“1. That the immediate transfer of Miss Overy the day after her 18th birthday was not in her best interests, was detrimental to her mental health and occurred purely due to the operation of s 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it, lest they be in breach of the act. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes; Unsafe transition and continuity of care from child to adult healthcare.

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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

Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.

Verbatim wording from the response

“You were concerned that there is no provision for secure mental health care for young adults aged 18–24 with a similar clinical picture. Whilst there are no dedicated wards for 18 to 24 year olds, there are wards that meet the clinical needs of patients with the same and similar presentation to Miss Overy. There is transition guidance in place which advises that arrangements are made within adult wards to ensure that appropriate patient needs, as highlighted in clinical assessments, are met. Receiving providers should make appropriate plans and extend the services available to aid the transition arrangements for young adults.”

Source location

2014-0535R
Page 4 · response
Published 17 December 2014

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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

The cited legislation is not known to require immediate transfer, preventing comment on that specific issue pending clarification.

Verbatim wording from the response

“You refer to the “operation of a section 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer”. I am not aware of a provision from either the Health and Social Care Act or the Mental Health Act which stipulates this, so am unable to comment on this specific matter. However, if you are able to provide clarification for this reference I am happy to respond further on this point.”

Source location

2014-0535R
Page 3 · response
Published 17 December 2014

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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

The transfer was planned for months, clinically assessed as appropriate, and could not safely be delayed or replaced by community discharge.

Verbatim wording from the response

“NHS England have assured me that Miss Overy’s future care had been considered for many months prior to her transfer including the appropriate type of environment and level of security required. They have confirmed that an independent clinical access assessment had been undertaken that identified that Miss Overy should be in an adult low secure placement when she turned 18. The CAMHS placement where she was, was not of a low secure environmental or therapeutic standard that would meet her identified needs. In addition, Miss Overy’s significant levels of risk and patterns of behaviour meant that she would not have been able either to remain within a CAMHS or be discharged to the community when she became an adult.”

Source location

2014-0535R
Page 3 · response
Published 17 December 2014

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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.2

  1. 1

    Commission the Children and Young People’s Mental Health and Wellbeing Taskforce to improve the organisation, commissioning and provision of children’s mental health services.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 17 December 2014.
  2. 2

    Revise the Mental Health Act Code of Practice with strengthened requirements for admission assessments, involvement of patients and families, and individualised behaviour support plans.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 17 December 2014.

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

Commission the Children and Young People’s Mental Health and Wellbeing Taskforce to improve the organisation, commissioning and provision of children’s mental health services.

Verbatim wording from the response

“In addition, I commissioned the Children and Young People’s Mental Health and Wellbeing Taskforce in August 2014 to improve the way children and young people’s mental health services are organised, commissioned and provided to make it easier for young people to access help and support. Transition is one of the key issues I have asked the Taskforce to address.”

Source location

2014-0535R
Page 2 · response
Published 17 December 2014

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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

Revise the Mental Health Act Code of Practice with strengthened requirements for admission assessments, involvement of patients and families, and individualised behaviour support plans.

Verbatim wording from the response

“The Department of Health is currently revising the Code of Practice, which will come into effect from 1 April. The Department has worked with partners, expert bodies and an extensive range of stakeholders including mental health professionals, carers, advocates and service users to strengthen the Code of Practice in key areas.”

Source location

2014-0535R
Page 4 · response
Published 17 December 2014

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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