PFD report

Christopher Richard ALLUM · Prevention of Future Deaths report

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Issued 10 Nov 2023•East Sussex

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

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 raised3

  1. Unavailability of NHS notes to private healthcare providers at admission
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure to obtain and record previous methods of self-harm and suicide at referral and admission
    Part of recurring concern: Failure to make previous self-harm and suicide-risk information available for safety assessmentsPart of recurring concern: Unreliable recording of suicide-risk information
  3. Failure to seek and record relevant information from family at referral and admission
    Part of recurring concern: Failure to obtain relevant collateral information from family and social supportsPart of recurring concern: Incomplete clinical history-taking
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.9

  1. Action

    Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.

    Stated by The Langford CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
  2. Action

    Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.

    Stated by The Langford CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
  3. Action

    Amend initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.

    Stated by The Langford CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Obtaining information from an informal patient’s family depends on the patient’s consent.

    Stated by The Langford CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Unavailability of NHS notes to private healthcare providers at admission

Wider context from the report

“Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care. Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 obtain and record previous methods of self-harm and suicide at referral and admission

Wider context from the report

“Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care. Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan. ”

Is this part of a recurring concern?

Yes — Failure to make previous self-harm and suicide-risk information available for safety assessments; Unreliable recording of suicide-risk information.

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 seek and record relevant information from family at referral and admission

Wider context from the report

“Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care. Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan. ”

Is this part of a recurring concern?

Yes — Failure to obtain relevant collateral information from family and social supports; Incomplete clinical history-taking.

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

Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.

Verbatim wording from the response

“In order to further explore possible past suicide attempts and to ensure full capture of a patient’s self-harm history at the admission stage, both the initial medical assessment and formation of risk assessment, completed by the triaging doctor at Langford, include the same subsections.”

Source location

Response from Bramley Health
Page 2 · response
Published 14 November 2023

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

Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.

Verbatim wording from the response

“Finally, as there have been amendments to our initial processes, training updates have been rolled out company wide. This includes training to staff who triage our initial referral documents, medical doctors who conduct the initial assessments and consultants who oversee our ward rounds and MDT’s. All staff have been fully informed of the additional processes and the sensitivities surrounding the nature and detail of the information being requested.”

Source location

Response from Bramley Health
Page 3 · response
Published 14 November 2023

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

Amend initial medical and risk assessments to record consent, next-of-kin details, and information obtained from patients’ families.

Verbatim wording from the response

“b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.”

Source location

Response from Bramley Health
Page 2 · response
Published 14 November 2023

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 staff to obtain family contact information and speak with next of kin when agreed, recording the information provided.

Verbatim wording from the response

“If agreed, a qualified member of staff is subsequently tasked with reaching out to the family and recording vital information. The document includes a section to record the information provided by a family or relative. Obtaining contact information and speaking with the next of kin are now a mandatory task at Langford.”

Source location

Response from Bramley Health
Page 3 · response
Published 14 November 2023

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 qualified medical staff with read-only access to referred patients’ NHS medical records.

Verbatim wording from the response

“I note that in relation to your further concern relating to difficulties in accessing a patient’s NHS notes, you made reference during your conclusions to the unprecedented steps The Langford”

Source location

Response from Bramley Health
Page 1 · response
Published 14 November 2023

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

Amend the initial referral form to require referrers to record previous suicide methods and self-harm methods, with explanations for incomplete information.

Verbatim wording from the response

“In order to address concerns relevant to The Langford Centre, we have been liaising with SPFT, and the following corrective measures have been agreed with our partners to be implemented from 1st January 2024;”

Source location

Response from Bramley Health
Page 2 · response
Published 14 November 2023

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

Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.

Verbatim wording from the response

“Christopher’s case does highlight the importance of effective information sharing to support providing the best care possible where individuals are transferred between different care settings. That is why joined up partnership working is one of the four key principles underpinning NHS England’s guidance on Acute inpatient mental health care for adults and older adults that was published in July 2023. This document provides specific advice on good practice on information sharing as well as guidance on the holistic assessment that should take place when someone enters a new facility, including identifying any safeguarding or risk issues, including risk to self and others. This includes guidance on the key actions that should take place within 72 hours of admission which include:”

Source location

Response from NHS England
Page 2 · response
Published 14 November 2023

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

Enhance sharing of patient information with commissioned voluntary, charitable, social enterprise and independent-sector providers.

Verbatim wording from the response

“NHS England is working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent sector providers who are commissioned by NHS organisations.”

Source location

Response from NHS England
Page 3 · response
Published 14 November 2023

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

Increase the role of family voice in the inpatient transformation programme.

Verbatim wording from the response

“In 2022, NHS England also established its Mental Health, Learning Disability and Autism Inpatient Transformation Programme to support cultural change and”

Source location

Response from NHS England
Page 2 · response
Published 14 November 2023

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

Obtaining information from an informal patient’s family depends on the patient’s consent.

Verbatim wording from the response

“b) In respect of seeking information from an informal patient’s family, this step is entirely dependent upon the individual’s consent.”

Source location

Response from Bramley Health
Page 2 · response
Published 14 November 2023

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

Referring Trusts or bodies are responsible for completing previous suicide-method information in the initial referral form.

Verbatim wording from the response

“a) Our initial referral form has been amended to include an additional field, entitled ‘Previous Suicide Methods’, which must be completed by the referrer. This field includes a supporting sub-section headed ‘Previous Suicide Methods Used,’ which is intended to record details of the self-harm methods.”

Source location

Response from Bramley Health
Page 2 · response
Published 14 November 2023

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 Langford Centre, operated by an independent provider, is the appropriate organisation to respond to concerns about information collection and recording.

Verbatim wording from the response

“The Langford Centre is operated by Bramley Healthcare, an independent Mental Health Care Provider providing services within the South of England. I note that you have also addressed your Report to the Centre, and they would be the appropriate organisation to respond to the above concerns. NHS England will carefully review and consider their response to you.”

Source location

Response from NHS England
Page 1 · response
Published 14 November 2023

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

Integrated Care Boards are responsible for determining which independent providers connect to local Shared Care Records and supporting their connection.

Verbatim wording from the response

“NHS England is working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent sector providers who are commissioned by NHS organisations.”

Source location

Response from NHS England
Page 3 · response
Published 14 November 2023

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.3

  1. 1

    Continue collaborating with partners to develop the referral form and strengthen admission information about patients’ risks and circumstances.

    Stated by The Langford CentreStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2023.
  2. 2

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across the NHS nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
  3. 3

    Support independent-sector providers to replace risk assessment tools with co-produced safety planning in line with relevant guidance.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 November 2023.

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 collaborating with partners to develop the referral form and strengthen admission information about patients’ risks and circumstances.

Verbatim wording from the response

“We continue to collaborate with our working partners in continuing to improve and strengthen our admission processes. The Langford Centre is committed to working with its partners in continuing to develop the referral form to ensure that the referring individual is admitted with as comprehensive and robust an account of the patient’s risks and circumstances.”

Source location

Response from Bramley Health
Page 3 · response
Published 14 November 2023

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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across the NHS nationally and regionally.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 3 · response
Published 14 November 2023

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

Support independent-sector providers to replace risk assessment tools with co-produced safety planning in line with relevant guidance.

Verbatim wording from the response

“In 2022, NHS England also established its Mental Health, Learning Disability and Autism Inpatient Transformation Programme to support cultural change and”

Source location

Response from NHS England
Page 2 · response
Published 14 November 2023

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