PFD report

Eve Cullen · Prevention of Future Deaths report

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Issued 8 Jan 2015•Worcestershire

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised5

  1. Failure to action received mental health referrals
    Part of recurring concern: Unreliable mental health referral pathways
  2. Lack of service-wide definitions for referral urgency levels
    Part of recurring concern: Unreliable referral urgency categorisation and prioritisation
  3. Failure to treat clinically identified urgent referrals as urgent
    Part of recurring concern: Unreliable urgent mental health referral and assessment pathways
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

    Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
  2. Action

    Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
  3. Action

    Implement the standardised urgent-referral process in Wyre Forest.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The 4 July referral was received, and urgent follow-up was not initially indicated; it was scheduled for weekly multidisciplinary review.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustDisputes 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 action received mental health referrals

Wider context from the report

“(1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an 'urgent' referral I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient. I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made. ”

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

Lack of service-wide definitions for referral urgency levels

Wider context from the report

“(1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an 'urgent' referral I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient. I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made. ”

Is this part of a recurring concern?

Yes — Unreliable referral urgency categorisation and prioritisation.

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 treat clinically identified urgent referrals as urgent

Wider context from the report

“(1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an 'urgent' referral I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient. I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made. ”

Is this part of a recurring concern?

Yes — Unreliable urgent mental health referral and assessment 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 record a suggested timeframe for action on referrals

Wider context from the report

“(1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an 'urgent' referral I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient. I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made. ”

Is this part of a recurring concern?

Yes — Insufficient detail in referrals for safe risk assessment and prioritisation; 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

Unstructured allocation of initial review timing to an individual psychiatrist

Wider context from the report

“(1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an 'urgent' referral I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient. I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made. ”

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

Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.

Verbatim wording from the response

“Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest.”

Source location

2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 2 · response
Published 8 January 2015

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 a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.

Verbatim wording from the response

“Unfortunately, it has not to date been the case that the same process applies in respect of the other areas in which the Trust provides services in Worcestershire, however we are working with the North CCG’s to address this, as it is our ambition to introduce a standardised system across the County. The Trust is working towards performance measures for all categories of referrals and will incorporate into a policy, which will distinguish between urgent and routine referrals with defined timescales for contact.”

Source location

2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 1 · response
Published 8 January 2015

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 the standardised urgent-referral process in Wyre Forest.

Verbatim wording from the response

“Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest.”

Source location

2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 2 · response
Published 8 January 2015

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

Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.

Verbatim wording from the response

“I confirm that since receiving your correspondence the Trust has written to all general practitioners in Redditch & Bromsgrove on 4 February 2015 identifying a protocol for the referral of mental health patients and the timescales in which they can be seen. This clarifies that referrals marked urgent should be triaged within 24 hours. The triage process may involve a discussion with the referrer, a discussion with the individual and/or a face to face assessment.”

Source location

2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 1 · response
Published 8 January 2015

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 4 July referral was received, and urgent follow-up was not initially indicated; it was scheduled for weekly multidisciplinary review.

Verbatim wording from the response

“One issue that I do need to raise with you is in respect of the referral from the Queen Elizabeth Hospital dated 4 July 2014 which you did not believe had been actioned by the community mental health team. Having reviewed this matter, it was clarified that the referral dated 4 July 2014 was received by the community mental health team on 11 July 2014. Discussion with the Queen Elizabeth RAID (rapid assessment interface, discharge) confirmed that at the point of the referral urgent follow-up was not indicated, as a result the referral was due to be reviewed by the weekly multidisciplinary team meeting.”

Source location

2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 2 · response
Published 8 January 2015

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

    Use the new Company Secretary to lead on inquests and ensure coroners receive appropriate information for full inquiries into deaths.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.

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

Use the new Company Secretary to lead on inquests and ensure coroners receive appropriate information for full inquiries into deaths.

Verbatim wording from the response

“I recognise that the Trust did not ensure that you had all the appropriate evidence available at the inquest in respect of the initial involvement of the CMHT. As you are aware the Trust has recently recruited a new Company Secretary who will be leading on inquests, and will be seeking to ensure that you are provided with appropriate information to enable you to conduct a full inquiry into the circumstances of deaths.”

Source location

2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 2 · response
Published 8 January 2015

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