PFD report

Liam Joseph LYES-WATSON · Prevention of Future Deaths report

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Issued 27 Sep 2022•Shropshire, Telford and Wrekin

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
12

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. Lack of training for call handlers
  2. Failure to act adequately on information received from callers
  3. Failure of advising colleagues to speak directly with callers
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.7

  1. Action

    Deliver suicide-prevention training to all Access Team call handlers, record completion, monitor compliance through supervision, and include annual training in mandatory records.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 October 2022.
  2. Action

    Require new call handlers to shadow trained colleagues, receive supervised-call experience, and be assessed as competent before independent work.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
  3. Action

    Provide call-handler supervision, maintain mandatory-training compliance, and address identified learning needs through monthly Quality Lead meetings.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.

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 training for call handlers

Wider context from the report

“(1) Four areas of concern are; a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller. b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him. c. With that information more should have been done. d. Consideration should be given whether incoming calls to the Access Team should be recorded. ”

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

Failure to act adequately on information received from callers

Wider context from the report

“(1) Four areas of concern are; a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller. b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him. c. With that information more should have been done. d. Consideration should be given whether incoming calls to the Access Team should be recorded. ”

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

Failure of advising colleagues to speak directly with callers

Wider context from the report

“(1) Four areas of concern are; a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller. b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him. c. With that information more should have been done. d. Consideration should be given whether incoming calls to the Access Team should be recorded. ”

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

Failure to discuss cases with callers while accepting information from them

Wider context from the report

“(1) Four areas of concern are; a. The call handler on the second occasion was not trained and needed to take professional advice from a colleague which colleague did not then speak directly with the caller. b. The apparent blanket response that they could not discuss the case with the caller yet they could take information from him. c. With that information more should have been done. d. Consideration should be given whether incoming calls to the Access Team should be recorded. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Deliver suicide-prevention training to all Access Team call handlers, record completion, monitor compliance through supervision, and include annual training in mandatory records.

Verbatim wording from the response

“We have reviewed the suicide prevention awareness training for call handlers and the decision has been made that all call handlers will have received the training below by the end of November 2022 https://www.zerosuicidealliance.com/training. A record of who has received this training will be held by the team manager and compliance monitored through supervision. In addition to this training, it has been agreed by the service manager that the training offered by Shropshire Council’s Joint Training in Suicide Prevention Awareness Suicide prevention | Shropshire Council is undertaken by all call handlers in the Access Team on a yearly basis and that this is built into their mandatory training for recording purposes on their electronic staff record.”

Source location

Response from Midlands Partnership NHS Trust
Page 2 · response
Published 7 October 2022

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

Require new call handlers to shadow trained colleagues, receive supervised-call experience, and be assessed as competent before independent work.

Verbatim wording from the response

“We have reviewed the training needs for all call handlers. All new call handlers will only shadow trained colleagues until they have completed their training and then will be supervised whilst taking calls until assessed as competent by the Quality Lead.”

Source location

Response from Midlands Partnership NHS Trust
Page 2 · response
Published 7 October 2022

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

Provide call-handler supervision, maintain mandatory-training compliance, and address identified learning needs through monthly Quality Lead meetings.

Verbatim wording from the response

“The Call Handler has discussed in supervision meetings with the Quality Lead of the Access Team on a monthly basis since the Serious Incident. All concerns regarding their working practice have been addressed. These meetings also ensure all Mandatory Training is up to date and learning needs have been addressed. These meetings have led to the following further training:”

Source location

Response from Midlands Partnership NHS Trust
Page 2 · response
Published 7 October 2022

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

Reinforce that family concerns require referral to the shift coordinator and that coordinators must speak with relatives to clinically formulate behavioural changes.

Verbatim wording from the response

“• We have reinforced to all call handlers that concerns raised by family members are of high significance and must be referred to the shift co-ordinator. We have stressed the importance to all shift co-ordinators that, where family are expressing concerns, they must speak to them to clinically formulate the changes in behaviours.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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

Provide the call handler with Stress and Resilience and Zero Suicide Alliance training.

Verbatim wording from the response

“• The Call Handler has attended a Stress and Resilience course to help them understand how to manage their own emotional responses to difficult calls received during their work.”

Source location

Response from Midlands Partnership NHS Trust
Page 2 · response
Published 7 October 2022

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

Share the carers’ confidentiality guide with Access Team staff and reinforce appropriate information-gathering and support through team meetings.

Verbatim wording from the response

“We have shared MPFT’s Guide to Carers Confidentiality with all the staff in the Access Team. This reinforces the message to our staff that a confidentiality breach only occurs when new, person identifiable, information is given to a third party and does not exclude gathering information from carers and providing them with support and advice. This message has been reinforced in team meetings in October 2022.”

Source location

Response from Midlands Partnership NHS Trust
Page 2 · response
Published 7 October 2022

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

Provide the newly published carers’ confidentiality guide and undertake Triangle of Care training for Access and Crisis Team staff.

Verbatim wording from the response

“• The Call Handlers have been provided with MPFT’s newly published Guide to Carers Confidentiality and are awaiting the Triangle of Care Training that all staff on the Access and Crisis Teams will be undertaking to enhance their skills when communicating with family members in contact with their teams.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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.5

  1. 1

    Share learning from the missed opportunity with the team to support re-engagement of service users who disengage.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
  2. 2

    Review whether Access Team call recordings can be retained for longer than the current 30-day period.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 October 2022.
  3. 3

    State during calls that recordings are used for training and audit purposes.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
  4. 4

    Develop new carer guidance containing support resources, safety-planning information, emergency-help advice, and links to approved resources.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2022.
  5. 5

    Retrieve and secure relevant Access Team calls within 30 days after serious-incident notification when an unexpected death is reported.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The specific calls could not be retrieved because recordings were automatically erased after the 30-day storage period.

    Stated by Midlands Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Share learning from the missed opportunity with the team to support re-engagement of service users who disengage.

Verbatim wording from the response

“• We recognise that the shift co-ordinator should have spoken to Mr Heaton and listened to his and Liam’s mother’s concerns. We apologise for this omission and learning from this missed opportunity has been shared with the Team to ensure all attempts are made to re-engage service users who disengage.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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

Review whether Access Team call recordings can be retained for longer than the current 30-day period.

Verbatim wording from the response

“The Trust and the investigator apologise for mistakenly stating that the calls to the Access Team are not recorded. All calls are recorded and are kept for audit and quality assurance and kept by the company who provides the service for 30 days. The Trust has requested that the company examine whether they can access the recording in question and will be reviewing whether calls can be kept for a longer period of time.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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

State during calls that recordings are used for training and audit purposes.

Verbatim wording from the response

“It is not stated on the call that the calls are recorded for training and audit purposes which is a matter that we have rectified. In future it has been agreed that when an unexpected death is reported that the relevant call will be retrieved immediately and reviewed as a part of the investigation process.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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 new carer guidance containing support resources, safety-planning information, emergency-help advice, and links to approved resources.

Verbatim wording from the response

“We are also developing new guidance for carers which contains a range of resources to provide support to carers in the form of a fact sheet which will include:”

Source location

Response from Midlands Partnership NHS Trust
Page 2 · response
Published 7 October 2022

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

Retrieve and secure relevant Access Team calls within 30 days after serious-incident notification when an unexpected death is reported.

Verbatim wording from the response

“It is not stated on the call that the calls are recorded for training and audit purposes which is a matter that we have rectified. In future it has been agreed that when an unexpected death is reported that the relevant call will be retrieved immediately and reviewed as a part of the investigation process.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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 specific calls could not be retrieved because recordings were automatically erased after the 30-day storage period.

Verbatim wording from the response

“The Trust and the investigator apologise for mistakenly stating that the calls to the Access Team are not recorded. All calls are recorded and are kept for audit and quality assurance and kept by the company who provides the service for 30 days. The Trust has requested that the company examine whether they can access the recording in question and will be reviewing whether calls can be kept for a longer period of time.”

Source location

Response from Midlands Partnership NHS Trust
Page 3 · response
Published 7 October 2022

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