PFD report

Nathan Anthony Lowe · Prevention of Future Deaths report

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Issued 19 Aug 2016•City of London

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
11

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. Insufficient contact with a patient who is non-compliant with follow-up
    Part of recurring concern: Failure to maintain follow-up of patients who disengage from care
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

    Record clear actions, deadlines and responsible leads from multidisciplinary meetings in meeting notes and electronic service-user records.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.
  2. Action

    Strengthen team leadership and oversight of follow-up and multidisciplinary decision-making for service users with complex needs.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.
  3. Action

    Review care-coordinator caseloads to identify further actions required.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2016.

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 contact with a patient who is non-compliant with follow-up

Wider context from the report

“Whether or not more should have been done to make contact with the patient between the 10th March and 12th May given the nature of his illness and the fact of his non-compliance with follow up. Such consideration is relevant to a Coroner’s duty in connection with the prevention of future deaths ”

Is this part of a recurring concern?

Yes — Failure to maintain follow-up of patients who disengage from care.

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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

Record clear actions, deadlines and responsible leads from multidisciplinary meetings in meeting notes and electronic service-user records.

Verbatim wording from the response

“3. Clear actions and timeframes by when these actions will be completed and by whom, are now more clearly recorded in the notes of each MDT meeting. These actions and associated timeframes and leads are also recorded in the service users’ electronic record.”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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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

Strengthen team leadership and oversight of follow-up and multidisciplinary decision-making for service users with complex needs.

Verbatim wording from the response

“I am aware that immediately following completion of the serious incident report the Service Line Lead responsible for this Quadrant met with the North West Adult community team members to discuss the learning and take the opportunity to personally review existing processes to look at ways in which the multi-disciplinary ways of working could be strengthened. The following actions have been taken since that time:”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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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

Review care-coordinator caseloads to identify further actions required.

Verbatim wording from the response

“5. A review of the care coordinators case load is being undertaken to identify if there are any further areas where actions may need to be taken”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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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

Pilot a clinical zoning tool in two community teams to identify high-risk service users requiring increased monitoring and intervention.

Verbatim wording from the response

“6. A clinical zoning tool is being piloted in two community teams including the North West. Through training this will assist in identifying those service users in each of the community teams who have high risk factors that require increased monitoring and interventions by the multi-disciplinary members of the clinical team.”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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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.7

  1. 1

    Continue the collaborative Spot the Signs, Save a Life suicide-prevention campaign to educate the public and primary-care staff about suicidality.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.
  2. 2

    Share learning from the action plan across Trust teams using a learning summary.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.
  3. 3

    Establish a Lead Pharmacist/Medicines Safety Officer role to identify and implement learning on medication incidents, medicines reconciliation and joint working with GPs.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2016.
  4. 4

    Develop and deliver clinical risk training on suicide-risk factors and risk-management decision-making to community teams.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.
  5. 5

    Participate in the Hertfordshire Suicide Prevention stakeholder event to develop a county-wide suicide prevention strategy.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 August 2016.
  6. 6

    Review mandatory clinical-risk training to include serious-incident case studies, with a designated Project Lead.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2016.
  7. 7

    Improve communication between professionals during multidisciplinary team meetings.

    Stated by Hertfordshire Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.

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 the collaborative Spot the Signs, Save a Life suicide-prevention campaign to educate the public and primary-care staff about suicidality.

Verbatim wording from the response

“This builds on work by the Hertfordshire Spot the Signs, Save a Life suicide prevention campaign which was launched in collaboration with Hertfordshire Mind Network, local GP surgeries and the East and North Herts Clinical Commissioning Group building on work undertaken in Detroit on suicide prevention by Dr Ed Coffey. This is one of four ‘Zero”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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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

Share learning from the action plan across Trust teams using a learning summary.

Verbatim wording from the response

“An action plan has been put in place to address these areas of learning which has been shared with our local Clinical Commissioning Group. The action plan will continue to be monitored by the Service Line Lead and the Managing Director until the actions taken to address the recommendations are fully implemented into clinical practice. The learning has also been shared more widely across other Trust teams by use of a learning summary.”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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

Establish a Lead Pharmacist/Medicines Safety Officer role to identify and implement learning on medication incidents, medicines reconciliation and joint working with GPs.

Verbatim wording from the response

“8. A Lead Pharmacist/Medicines Safety Officer has commenced in post; part of this key role will be to identify and implement learning in relation to medication incidents which will include ways in which medicines reconciliation and joint working between GP’s and the Trust can be improved.”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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 and deliver clinical risk training on suicide-risk factors and risk-management decision-making to community teams.

Verbatim wording from the response

“7. As part of a quality improvement initiative a specific clinical risk training package around increasing awareness of suicide risk factors to support risk management decision making has been developed and delivered to the community teams in the North West and East and South East Quadrants.”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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

Participate in the Hertfordshire Suicide Prevention stakeholder event to develop a county-wide suicide prevention strategy.

Verbatim wording from the response

“As part of the Trust’s commitment to a zero suicide ambition, on 9 November 2016, the Trust is participating in a Public Health led Hertfordshire Suicide Prevention stakeholder event. The aim of the event is to bring together representatives of the many diverse organisations who together can achieve the vision of making Hertfordshire a county where no one ever gets to a point where they feel suicide is their only option and to develop a Hertfordshire wide suicide prevention strategy. Speakers on the day will include a train driver, a service user with lived experience of surviving a suicide attempt and a family bereaved by suicide.”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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 mandatory clinical-risk training to include serious-incident case studies, with a designated Project Lead.

Verbatim wording from the response

“Clinical risk training is a mandatory training requirement for staff in clinical roles to attend every three years. The Trust is at present reviewing this training programme to include more serious incident case studies to encourage discussion amongst attendees and inform clinical practice. A Project Lead has been identified.”

Source location

Nathan-Lowe-Response
Page 3 · response
Published 19 August 2016

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

Improve communication between professionals during multidisciplinary team meetings.

Verbatim wording from the response

“I am aware that immediately following completion of the serious incident report the Service Line Lead responsible for this Quadrant met with the North West Adult community team members to discuss the learning and take the opportunity to personally review existing processes to look at ways in which the multi-disciplinary ways of working could be strengthened. The following actions have been taken since that time:”

Source location

Nathan-Lowe-Response
Page 2 · response
Published 19 August 2016

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