PFD report

George Christian Werb · Prevention of Future Deaths report

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Issued 19 Nov 2014•Exeter & Greater Devon

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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. Failure to provide locally accessible child psychiatric inpatient care
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
  2. Insufficient availability of child psychiatric inpatient beds
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
  3. Ineffective multidisciplinary CPA meeting participation and communication
    Part of recurring concern: Unsafe operation of multidisciplinary clinical meetings
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

    Commission additional Huntercombe capacity in Torquay, comprising six generic and four psychiatric intensive-care beds, through phased opening.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2014.
  2. Action

    Reopen Wessex House in phases to provide twelve generic CAMHS beds in the South West.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2014.
  3. Action

    Implement weekly CAMHS bed-capacity reporting and national case-manager teleconferences to support timely identification of available placements.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The review identified contributory issues but could not conclusively establish that suicide would have been prevented without them or that distance caused the death.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 locally accessible child psychiatric inpatient care

Wider context from the report

“(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients. (2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time. (3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support. (4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need. (5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties. (6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care. (7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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

Insufficient availability of child psychiatric inpatient beds

Wider context from the report

“(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients. (2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time. (3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support. (4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need. (5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties. (6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care. (7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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

Ineffective multidisciplinary CPA meeting participation and communication

Wider context from the report

“(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients. (2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time. (3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support. (4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need. (5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties. (6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care. (7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death. ”

Is this part of a recurring concern?

Yes — Unsafe operation of multidisciplinary clinical meetings.

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

Lack of an effective bed bureau system for identifying child psychiatric bed spaces

Wider context from the report

“(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients. (2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time. (3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support. (4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need. (5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties. (6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care. (7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death. ”

Is this part of a recurring concern?

Yes — Unreliable hospital bed bureau systems for identifying available beds.

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

Commission additional Huntercombe capacity in Torquay, comprising six generic and four psychiatric intensive-care beds, through phased opening.

Verbatim wording from the response

“The South West region can now also report that Wessex House, Bridgewater, Somerset is now in the process of a phased reopening. There are currently four generic beds open, with a further four opening during January 2015 and the full twelve bed commitment will be open by March 2015. In addition there has been a further six generic beds and four Psychiatric Intensive Care Unit (PICU) beds commissioned from the Huntercombe Group with a unit now based in Torquay, Devon. Again this unit has a phased opening plan, with four generic beds currently open, a further two will open during January 2015 and the PICU beds will be available by the end of January 2015. In total this will give the South West a total of fifty two generic beds and four PICU beds.”

Source location

2014-0510-Response-by-NHS-England
Page 3 · response
Published 19 November 2014

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

Reopen Wessex House in phases to provide twelve generic CAMHS beds in the South West.

Verbatim wording from the response

“The South West region can now also report that Wessex House, Bridgewater, Somerset is now in the process of a phased reopening. There are currently four generic beds open, with a further four opening during January 2015 and the full twelve bed commitment will be open by March 2015. In addition there has been a further six generic beds and four Psychiatric Intensive Care Unit (PICU) beds commissioned from the Huntercombe Group with a unit now based in Torquay, Devon. Again this unit has a phased opening plan, with four generic beds currently open, a further two will open during January 2015 and the PICU beds will be available by the end of January 2015. In total this will give the South West a total of fifty two generic beds and four PICU beds.”

Source location

2014-0510-Response-by-NHS-England
Page 3 · response
Published 19 November 2014

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

Implement weekly CAMHS bed-capacity reporting and national case-manager teleconferences to support timely identification of available placements.

Verbatim wording from the response

“Since August 2013, NHS England has implemented a situation report (SITREP) process each Friday which requires all Child and Adolescent Mental Health Services (CAMHS) inpatient providers to submit numbers of available beds to a national database. This data is used to produce a report that is available from lunch time on a Friday indicating available capacity at each of the inpatient services commissioned. The report is circulated via the Area Teams to all Tier 3/Community CAMHS so they can identify capacity as required and particularly on a Friday when there is often a peak in demand and over the weekend.”

Source location

2014-0510-Response-by-NHS-England
Page 2 · response
Published 19 November 2014

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

Commission additional general CAMHS and psychiatric intensive-care capacity from existing providers, targeting 50 additional beds nationally.

Verbatim wording from the response

“NHS England has conducted two separate processes during 2014 to identify and commission additional inpatient general CAMHS and psychiatric intensive care capacity from existing providers that should result in an additional 50 beds nationally by the end of the financial year. This includes additional capacity in the South West area.”

Source location

2014-0510-Response-by-NHS-England
Page 2 · response
Published 19 November 2014

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 review identified contributory issues but could not conclusively establish that suicide would have been prevented without them or that distance caused the death.

Verbatim wording from the response

“In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.”

Source location

2014-0510-Response-by-NHS-England
Page 4 · response
Published 19 November 2014

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

Finding an available psychiatric bed is the responsibility of the referring community CAMHS team.

Verbatim wording from the response

“Finding a bed is the responsibility of the referring community CAMHS team and they would have contacted available units and taken the bed that was made available to them. Whilst every effort is made to keep patients/children and young people as close to home as possible, sometimes lack of available beds mean that this cannot always happen.”

Source location

2014-0510-Response-by-NHS-England
Page 3 · response
Published 19 November 2014

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

    Rectify approval processes for CAMHS admissions and incorporate them into robust assessment and admission procedures.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2014.
  2. 2

    Share incident learning through contract meetings with the Priory Group and provider forums across Wessex House and the South of England.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2014.
  3. 3

    Recruit CAMHS case managers across all ten NHS England Area Teams to support timely access, discharge and resolution of placement delays.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2014.

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

  1. 1

    Priory Hospital Southampton is a commissioned twelve-bed general CAMHS service, not an overflow facility.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Rectify approval processes for CAMHS admissions and incorporate them into robust assessment and admission procedures.

Verbatim wording from the response

“The NHS England Area Team Bristol, North Somerset, Somerset, South Gloucester (BNSSSG) has no record of the prior approval for admission into the Priory Hospital. The young person’s admission was just after NHS England was established. The current processes for approval to admit were not being followed by all community teams and admission may well have taken place without the Area Team’s knowledge. This process has since been rectified and is now part of robust processes of assessment and admission. In respect of bed availability, there was at that time a shortage within the South West region due to the temporary closure of Wessex House, Bridgewater, Somerset. Following concerns regarding poor staffing levels and a number of significant incidents, it was decided that the unit was no longer viable to operate safely. This temporary closure remained in place for nearly two years.”

Source location

2014-0510-Response-by-NHS-England
Page 3 · response
Published 19 November 2014

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 incident learning through contract meetings with the Priory Group and provider forums across Wessex House and the South of England.

Verbatim wording from the response

“We also used the contract meeting process to ensure learning points from this incident were shared through the Priory Group and were assured that there were processes in place to do this.”

Source location

2014-0510-Response-by-NHS-England
Page 5 · response
Published 19 November 2014

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

Recruit CAMHS case managers across all ten NHS England Area Teams to support timely access, discharge and resolution of placement delays.

Verbatim wording from the response

“All ten NHS England Area Teams have recruited CAMHS case managers who have been instrumental in supporting timely and appropriate access to commissioned beds. The case managers work closely with providers and the community CAMHS teams to ensure timely discharge and to address barriers that may cause delays to those plans.”

Source location

2014-0510-Response-by-NHS-England
Page 2 · response
Published 19 November 2014

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

Priory Hospital Southampton is a commissioned twelve-bed general CAMHS service, not an overflow facility.

Verbatim wording from the response

“On the index admission George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for ‘overflow’ patients from across all England, many of whom are therefore huge distances from their home, their family, their friend and community support.”

Source location

2014-0510-Response-by-NHS-England
Page 3 · response
Published 19 November 2014

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