PFD report

Alex Alfred ROBINSON · Prevention of Future Deaths report

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Issued 28 May 2026•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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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. Failure to ensure a formal referral to MHLT
    Part of recurring concern: Unreliable mental health referral pathways
  2. Failure to provide accurate information about MHLT availability
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

    Require staff to document all contact with mental health professionals on the online referral form and retain a copy in the patient notes.

    Stated by Group Chief Medical OfficerStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
  2. Action

    Provide Trust-wide communications highlighting the need to use the online referral form.

    Stated by Group Chief Medical OfficerStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.

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 a formal referral to MHLT

Wider context from the report

“That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are available on site out of hours to review the patient physically”. In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time”. Subsequent inquiry with MHLT stated clearly that Midlands Partnership Foundation Trust (MPFT) Mental Health Liaison Team at RSH is a 24/7 service, they had the usual night cover of cover of two staff on the 8/9 September 2025 and that no formal referral was ever received. This conflicting information represents a lost opportunity for Alex to have received appropriate care from MPFT which may have prevented Alex from killing himself on the 10 September 2025, but this cannot be known. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 provide accurate information about MHLT availability

Wider context from the report

“That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are available on site out of hours to review the patient physically”. In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time”. Subsequent inquiry with MHLT stated clearly that Midlands Partnership Foundation Trust (MPFT) Mental Health Liaison Team at RSH is a 24/7 service, they had the usual night cover of cover of two staff on the 8/9 September 2025 and that no formal referral was ever received. This conflicting information represents a lost opportunity for Alex to have received appropriate care from MPFT which may have prevented Alex from killing himself on the 10 September 2025, but this cannot be known. ”

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

Require staff to document all contact with mental health professionals on the online referral form and retain a copy in the patient notes.

Verbatim wording from the response

“Our conclusion and learning from this is that all contact with MPFT needs to be documented on the online referral form and a copy kept in the notes. We believe this should resolve any ambiguity about advice received and therefore potentially reduce the risk that level of concern for a patient’s mental health has not been fully understood. We will also reiterate to staff the importance of recording the name of any healthcare professional who has given advice in the medical notes.”

Source location

Response from Shrewsbury and Telford Hospital NHS Trust
Page 2 · response
Published 28 July 2026

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 Trust-wide communications highlighting the need to use the online referral form.

Verbatim wording from the response

“We will provide Trust-wide communications to highlight the need to use the online referral form.”

Source location

Response from Shrewsbury and Telford Hospital NHS Trust
Page 2 · response
Published 28 July 2026

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.1

  1. 1

    Reiterate to staff the importance of recording the advising healthcare professional’s name in medical notes.

    Stated by Group Chief Medical OfficerStated plannedThe respondent said that this action was planned when they made their response on 28 July 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

Reiterate to staff the importance of recording the advising healthcare professional’s name in medical notes.

Verbatim wording from the response

“Our conclusion and learning from this is that all contact with MPFT needs to be documented on the online referral form and a copy kept in the notes. We believe this should resolve any ambiguity about advice received and therefore potentially reduce the risk that level of concern for a patient’s mental health has not been fully understood. We will also reiterate to staff the importance of recording the name of any healthcare professional who has given advice in the medical notes.”

Source location

Response from Shrewsbury and Telford Hospital NHS Trust
Page 2 · response
Published 28 July 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