PFD report

Bituin Pizzaro Pimlott · Prevention of Future Deaths report

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Issued 6 Sep 2021•Manchester South

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

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. Lack of clear guidance on when GPs should directly refer patients to the crisis team
    Part of recurring concern: Unreliable mental health referral pathways
  2. Failure to provide face-to-face mental health assessment when clinically needed
    Part of recurring concern: Failure to provide face-to-face mental health assessment when clinically indicated
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.6

  1. Action

    Develop joint guidance with the Royal College of General Practitioners on choosing remote or face-to-face consultations, including patient safety and safety-netting.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
  2. Action

    Produce and iteratively update standard operating procedures for safe remote general-practice services during changing pandemic requirements.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
  3. Action

    Reintroduce advance booking of face-to-face GP appointments across Stockport practices.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.

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

  1. Position

    Local mental health services and crisis-referral guidance are commissioned and addressed locally by the CCG, which is best placed to respond.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Lack of clear guidance on when GPs should directly refer patients to the crisis team

Wider context from the report

“The inquest heard evidence that Mrs Pimlott had been struggling with her mental health in the weeks preceding her death and had contacted her GP on a number of occasions with anxiety and depression. She was prescribed medication but expressed concerns about the impact of the medication. Telephone consultations rather than face to face appointments continued to be used with her due to the pandemic. Pre Covid it was accepted she would have been seen face to face which would have allowed a more comprehensive assessment of her mental health and her reluctance to use medication. Her GP practice did not refer her to the crisis team, and it was unclear what guidance the practice had for their GPs about when they should refer directly to the crisis team. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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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 face-to-face mental health assessment when clinically needed

Wider context from the report

“The inquest heard evidence that Mrs Pimlott had been struggling with her mental health in the weeks preceding her death and had contacted her GP on a number of occasions with anxiety and depression. She was prescribed medication but expressed concerns about the impact of the medication. Telephone consultations rather than face to face appointments continued to be used with her due to the pandemic. Pre Covid it was accepted she would have been seen face to face which would have allowed a more comprehensive assessment of her mental health and her reluctance to use medication. Her GP practice did not refer her to the crisis team, and it was unclear what guidance the practice had for their GPs about when they should refer directly to the crisis team. ”

Is this part of a recurring concern?

Yes — Failure to provide face-to-face mental health assessment when clinically indicated.

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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

Develop joint guidance with the Royal College of General Practitioners on choosing remote or face-to-face consultations, including patient safety and safety-netting.

Verbatim wording from the response

“Additionally, guidance was developed jointly between NHS England and the Royal College of General Practitioners (RCGP) on Remote vs Face to Face: which to use and when? and RCGP publish a range of guidance and learning materials on their Covid-19 Resource Hub. These resources underline the importance of ensuring patient safety, shared decision making and that an individual’s needs are paramount.”

Source location

Response from NHS England
Page 2 · response
Published 9 September 2021

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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

Produce and iteratively update standard operating procedures for safe remote general-practice services during changing pandemic requirements.

Verbatim wording from the response

“The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures (SOPs) were produced to ensure general practice is able to operate safely in this context. The SOP which was last published (now retired) which is relevant in this matter is attached for reference. I can confirm that SOPs were iterated throughout the pandemic to meet changing needs and requirements since first publication. This SOP was first published in March 2020.”

Source location

Response from NHS England
Page 2 · response
Published 9 September 2021

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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

Reintroduce advance booking of face-to-face GP appointments across Stockport practices.

Verbatim wording from the response

“Many patients informed us that they preferred to be able to book a face-to-face appointment in advance so as to enable them to manage their healthcare around other commitments and forward booking of appointments has therefore been re-introduced across the Stockport patch.”

Source location

Response from Stockport Clinical Commissioning Group
Page 2 · response
Published 9 September 2021

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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

Circulate mental-health referral-options information to Stockport GP practices and distribute it to patients.

Verbatim wording from the response

“I am satisfied that in addition to the offer of face-to-face consultations where appropriate / requested, there is a robust process of triage, to include safety netting, in circumstances where a patient presents via the telephone reporting mental health concerns. Many such patients are offered same day face-to-face appointments and an information sheet detailing options for referral has been re-circulated to all GP Practices in Stockport. This document was developed as a single sheet which can be shared with patients, setting down referral options. I have attached a copy of the document which has been delivered to every Stockport address.”

Source location

Response from Stockport Clinical Commissioning Group
Page 2 · response
Published 9 September 2021

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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

Provide patients with access to face-to-face GP consultations where clinically appropriate or directly requested.

Verbatim wording from the response

“• Access to blended appointments and patient choice in relation to the way in which they wish to consult with their GP”

Source location

Response from Stockport Clinical Commissioning Group
Page 1 · response
Published 9 September 2021

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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

Operate telephone triage with safety netting and same-day face-to-face appointments for patients reporting mental health concerns.

Verbatim wording from the response

“Appropriate consultations with safety netting”

Source location

Response from Stockport Clinical Commissioning Group
Page 2 · response
Published 9 September 2021

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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

Local mental health services and crisis-referral guidance are commissioned and addressed locally by the CCG, which is best placed to respond.

Verbatim wording from the response

“Finally in response to your secondary concern regarding unclear guidance for when GP practices should refer directly to the crisis team, I can confirm that Mental Health services are commissioned locally and to this end I note that the local CCG Medical Director has provided you with a separate response detailing relevant information and confirming steps that have been taken. The CCG are best placed to respond to this concern and they have kindly provided me with a copy of their response, the content of which I note, as well as a copy of the leaflet that has been developed and delivered to all households in the area listing the locally available Mental Health crisis facilities. I note that a reminder is also to be sent to all practices confirming the support available.”

Source location

Response from NHS England
Page 3 · response
Published 9 September 2021

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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

Existing remote-consultation procedures require safety-focused triage and clinician selection of consultation method according to each patient’s circumstances.

Verbatim wording from the response

“The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures (SOPs) were produced to ensure general practice is able to operate safely in this context. The SOP which was last published (now retired) which is relevant in this matter is attached for reference. I can confirm that SOPs were iterated throughout the pandemic to meet changing needs and requirements since first publication. This SOP was first published in March 2020.”

Source location

Response from NHS England
Page 2 · response
Published 9 September 2021

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

Existing appointment systems provide face-to-face consultations where clinically appropriate or directly requested, so further access changes are unnecessary.

Verbatim wording from the response

“• Access to blended appointments and patient choice in relation to the way in which they wish to consult with their GP”

Source location

Response from Stockport Clinical Commissioning Group
Page 1 · response
Published 9 September 2021

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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

Existing triage and safety-netting processes adequately manage telephone mental-health presentations, including same-day assessment and referral information.

Verbatim wording from the response

“Appropriate consultations with safety netting”

Source location

Response from Stockport Clinical Commissioning Group
Page 2 · response
Published 9 September 2021

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.2

  1. 1

    Deliver updated suicide-prevention presentations through the GP Masterclass programme.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
  2. 2

    Cascade anonymised learning from Regulation 28 reports and significant events through the Quality Board and to GP colleagues.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.

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

Deliver updated suicide-prevention presentations through the GP Masterclass programme.

Verbatim wording from the response

“In addition, as part of our GP Masterclass programme, presentations in relation to suicide prevention have been delivered with updates; the most recent in 2021.”

Source location

Response from Stockport Clinical Commissioning Group
Page 2 · response
Published 9 September 2021

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

Cascade anonymised learning from Regulation 28 reports and significant events through the Quality Board and to GP colleagues.

Verbatim wording from the response

“I can confirm that the practice involved in this case have completed a reflection exercise; learning from all Regulation 28 reports / significant events is cascaded at the Quality Board and shared anonymously with our GP colleagues.”

Source location

Response from Stockport Clinical Commissioning Group
Page 2 · response
Published 9 September 2021

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